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REV. 04109/99 <br /> SAN JOAQUIN COUNTY OUBLIC HEALTH SERVICES 8 ENVIRONMENT EALTH DIVISION <br /> MASTERFILE RECORD.INFORMATION <br /> DATE OWNER ID Y CASE E <br /> OWNER FILE <br /> COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION: CHECKIF OWNERCURRENnYONeuwnHEHD ❑ <br /> &aNEss OwNEc NunE <br /> PHONE <br /> Ni <br /> B N=NAME(MENFFEREMhem Ba"r .Name) SOC SEC/TAx IO Y <br /> �vO1W E-Al t S CCjAv! EK aF 5.4AI ,T0AcV 0111 (f, Nn/T y <br /> owNER�Ess <br /> toNagr# .SA-Al -7a,4*u1x) sre�z-r <br /> aN SToC-Tj STATE/ A- SIP cj S�Zd4- <br /> OwNERMuuNGAooRSS (tl DIfFFREMhwn OwnerAWieL) Attention:wCwed (OpBwwD <br /> Mciing Addrev CO, Std. Lp <br /> nK CF O.NfR V <br /> CORPORARON{ INDIVIDUAL go I PARTNERSHIP LOCALAGENCY COtJNTYAGENCYIC STATEAGENCYCI I FEDAGENCYli OMERt <br /> FACILITY FILE <br /> FACILITY ID# CROSS REF IOy <br /> ACCOUNT ID# <br /> COMPLETE THEFOLLOWING BUSINESS FACILITY INFORMATION: <br /> & NESS/FACRIIY N. E(TNu Wlu M ME NAME ON RIE HEALM PERM() <br /> AOIVON/S 6�N r&",2 OG S JAI �TD14,fOIn1 COUN7y <br /> FACIu AOoxss Oa CCMMISSMY.0.. $tM(y Bu4NES5P ONE <br /> (a Zo AMR»/ SAA! T7449MIAf SY/'—r <br /> CM O4 ccl.SSMI ADORSS STATE LP <br /> SFoGK7Ditl ("4 gSyoZ <br /> BOARDw$VifWIYW D..a LOCAnON CCOE KEYI KM <br /> HEALMPERMITMAILINGADDRESS(HDIFFEREWh FMU,y AW,es) AftnY :w Care Of(ophwnp <br /> Mailing AWrom City STAR LR <br /> sic CME APN CWMEM <br /> AccouwADDREss far fees and charges OWNER AGILITY/BUSINESS <br /> BILLING AND COMPLIANCE ACKNONVI.EDGNIENT: 1, the undersigned Applicant, certify that I am the Owner, Operator, or <br /> Authorized Agent of this Business, and 1 acknowledge that all PERJUT FEES,PENALTFES,ENFORCEMENT CHARGES and/or HOURLY <br /> CHARGES associated with this operation will be billed tonne at the address identified above as theACCOUNTADDRESS for this site. 1 <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 /> APPUCA NAME(Ae PMD AN <br /> JaEI.(.E C70ntiE� <br /> "TLE pl2C-CM12- <br /> E3Fdf&$VF dt�CD) <br /> Approved By Dde Acco nBng Ofllce PiociNMg Completed By Dde <br />