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SAN JOA N COUNTY ENVIRONMENTAL HEALTH F TARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> SHADED SECTIONS FOR EHD USE ONLY OWNER ID# or <br /> `� CASE# <br /> U <br /> OWNERFILE <br /> OMPLETE THEFOLLOWING BUSINESS OWNERNFORMATION' CHECKrF OWNER CURRENTI Y ON n1E WrTN EH D❑ <br /> BUSINESS HONE• Q <br /> OWNER'S NAME Fst MI Last L,�• rZ��/ <br /> BUSINESS NAME(If different from Owner Name) Soe Sec orTax ID tt <br /> ,v Aov, _ 4, C) <br /> OWNER'S HOME ADDRESS ZI /1/f Sr L� <br /> CITY J GN✓? K C/V STATE ZIP <br /> OWNER'SMAILING ADDRESS (IfdiffE tfrom Ownees Address) Attention orCare of <br /> MAILING ADDRESS CITY STATE ZIP <br /> TYPE OF OWNERSHIP: <br /> CORPORATION❑ INDIVIDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE �y <br /> FADILITYID#: < CO-OWNER ID#: ACCOUNT ID#: t� <br /> ComPLETETHEFouowrNaBUSINESS FACILITY rwogmnom, <br /> Is this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO ❑ <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ NO ❑ <br /> BUSINESS/FACILITY NAME(This will be the Br/.snvESSNAME n the HEALTH PERM <br /> ✓ -.�c a s - To Top/ J k4 Aif <br /> FACILITVADDRE5511fFiram'isaFKISRE UrFTZ7 �ieuse�g ) B Z. <br /> TN PHONE <br /> Y T/ LJv I/ Y /L�� SD, # �I <br /> re SZ J <br /> CITY(BFACX,1T1(sa MOen.EFOODUNrr rFOOD VEHICLEU the STAjLA�J') ZIP <br /> rZA 1114' <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE =EY1 KEY2 <br /> MAILING ADDRESS AOr Health Permft(If DIFFERENTfrom FacilityAddr ) Attention or Care Of <br /> MAILING ADDRESS CITY STATE zip <br /> SIG CODE: APIN#: COMMENT: <br /> drYQUAIT&WRLIG'for fees and charges: OWNER ❑ FACILITY/BUSINESS ❑ <br /> BIL I INn AND COMPI IANr..F Ar.KNnwi Fnr:MFNT; I,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and <br /> I acknowledge that all PERMIT FEES, PENALTIES, ENFORCEMENT CHARGES andfor HOURLY CHARGES associated with this Operation will be billed to me at the <br /> address identified above as the ACCOUNT ADORESfor this site. I also certify that all information provided on this application is true and correct;and that <br /> all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or <br /> FEDERAL Laws and Regulations. <br /> PPLICANT'S NAME4 SIGNATUREa <br /> Please Pnnt <br /> TITLE: r /' �j DATE (PHOTOCOPY RFnuxgFnl <br /> DRIVER'S LICENSE# <br /> Approved BY l_ Date <br /> /U S�/O Accounting Office Protetsin9 completed BY <br /> A PROGRAM (EHD 48-02-034 Pink) or WATER SYSTEM {EHD 46-02-003} form must be completed for each EHD regulated operation at this <br /> I CCATTf1N except UST Program(Use SWRCB forms) <br /> EHD 4"2-035 Masterfile Record-Green <br /> 8/19/08 <br />