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REV. 04/09/99 <br /> —'—�� <br /> SAN.JOAQUIN COUNTY FMBLIC HEALTH SERVICES B ENVIRONMENT EALTH DIVISION <br /> MASTERFILE RECORD INFORMATION <br /> DATE OWNER ID 6 1170 CASEY 1y y y <br /> ' 7 ( <br /> OWNER FILE <br /> IF NENRRENnY on FlN wrtH FHD <br /> COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION: APRCn CXS OWR ❑ <br /> M <br /> BumMss OWNER HAN* E N V I R DM EN,TA-L -I EALTf-^ <br /> m u <br /> �; / F <br /> Br¢INE$$NAMf(#DIFFEREAIT O BoWwss Name) SOC SEc/TA%IDY <br /> rLJ oa _ I ✓c- C (u h <br /> OWNER HOME ADDRESS <br /> O CPI <br /> City <br /> STATE Lr <br /> OWNERMAAINGACr> M (YDIFFERENTft mOwner Address) ARenEcn:wCared (DpIRxaD <br /> /-F1'rcEEw T� <br /> sloe ZIP <br /> Malllnq Address City <br /> ttPE OE OwNEirsHir /E�/EA71 <br /> CORPORATION INDIVIDUAL f PARTNERS IP A <br /> IP 0 LOCAL AGENCY 4 COUNTY AGENCY STATE GENCY FED AGENCY OTHER i <br /> /'' FACILITY FILE <br /> FACILITY IDR DO / I/ CROSS REF]Do ACCOUNT ID <br /> COMPLETE THE FOLLOWING E t%=FACILITY INFORMATION: <br /> &MMWIFACIM NAME(M¢rnu M ME NAME ON THE HEALTH PERMIT) <br /> 1 L <br /> $I.rIEY &wNEss PLANE <br /> FAClllrr ADCRE55 Ca CCMMESSNr ADDRESS b��v��� <br /> O o <br /> STAR Lr <br /> cm aR coMMEsswr ARonfss � /'77 / <br /> BDI1D a$VPERV¢aR D¢nncr <br /> LOCAs CODE KEVI KEY2 J J L !c7 <br /> AHenBon:a Cae Of(00orw9 <br /> HEALTH PERMR MAIDNG ADDRESS(p DIfFEREMhwn FOCWy Address) <br /> SIAM W <br /> Mallnq Address City <br /> SIC COOS APN COMMfM <br /> AccouFrt[tDORfM for fees and charges OWNER FACILITY/B1461NEbS• <br /> 1111.1.ING AND COMIII.IANCF ACKNOWI.FDGAIENT; 1, the undersigned Applicant, certify that I am the Owner, Operator, or <br /> Authorized Agent of this Business,and 1 acknowledge that all PERMIT FEES,PENALTIES, ENFORCEMENT CIIARGES and/or 1101IRLY <br /> CHARGE'S associated with this operation will be billed to me at the address identified above as the ACCOUNTADDRESS for this site. 1 <br /> also c'e'rtify that all information provided on this application is true and correct;and that all regulated activities will be performed <br /> in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or FEDERAI. Laws <br /> and Regulations. <br /> SIGNATURE <br /> APPLICANT NAME(Aerie PMD <br /> z o <br /> TIRE 1PE+0 ID) <br /> Approved BY Dae J AccounBn9 ottice PMocassln9 CDrnPlelad By <br /> Baa <br />