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REV. 04/09/99 <br /> SAN JOAQUIN COUNTY&UBUc HEALTH SERVICES 8 ENVIRONMEN HEALTH DIVISION <br /> • MASTERFILE RECORD INFORMATION <br /> DATE OWNER ID Y CASE Y <br /> OWNER FILE <br /> CNECKLF OWNER CURRENRYON FILE WIM END ❑ <br /> COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION; <br /> Br61NE4 OWNER NAME PNoNE <br /> - <br /> sl ast <br /> NunE(X DIFfFREMhom eusirress Nome) <br /> <br /> OwNEP MCAIE PLORE4 ^ 1 1. y� Erb <br /> `� ATE LR <br /> " — 2 <br /> OWNERMAIUNGALORss (YDIFFERENrrhom OwnerAddress) AB Man:wcweof (oPMonaO <br /> P•D • �3 b �Lem lv'YL <br /> Ilnp Address CMtiA-� 51 e L(r�Q7 <br /> TYPE w OwN€REwR <br /> CORPORATION V INDIVIDUAL PARTNERSHIP dn LOCAL AGENCY COUNTY AGENCY QVI STATE AGENCY FED AGENCY! OTHER f <br /> FACILITY FILE <br /> FACILITY ID# CROSS REF IDE ACCOUNT ID # <br /> COMPLETE THE FOLLOWING BUSINESS FACILITY INFORMATION: <br /> "NEM/FACILNY NAVE DN¢wu BE ME NAME ON THE HEALTH PERM(T) <br /> Rbn IL s,4Lu bU-L <br /> FACIun Aawrc4OR CCMMLSSIPr ACOREss SIRIEY "NESS PHONE <br /> cnjYw+�eo�lem4A�Rr A 0O 55 SmIE_ LP p� <br /> l.� L�r'Ey.JI <br /> BOAALICP SUPFINCCR DOTma LOCATIONCODE KEPI KEti2 <br /> HEALTH PERMR MAKING ADDRESS(YDIFFERENI` w Foculy Address) A"Wflon:w Cwe Of(OPlbnoO <br /> J � t <br /> MatEng Address CIN STATE W <br /> SIC CORE APN COMMENT <br /> gccoufrtAooggss for fees and charges OWNER FACILITY/BUSINESS <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I, the undersigned Applicant, certify that I am the Owner, Operator, or <br /> Authori.ed Agent or this Business,and I acknowledge that all PERAUT FEES,PENALTIES, ENFORCEMENT CHARGES and/or HOURLY <br /> CHARGES associated with this operation will be billed to me at the address identified above as the ACC'OUNTADDRES.S for this site. I <br /> also certify 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 FEDERAL. Laws <br /> and Regulations. <br /> APPLICANT NAME(Please PM,0 SIGNATURE <br /> TRLE 'f( bUS> 'dlfiRtO> ^ <br /> Approved BY Data ACCO nMng Office Proces ng C Pleled BY nate <br />