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t <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> f MASTERFILE RECORD'INFORMATION FORM <br /> I <br /> e <br /> SHADED SEC77ONSFOR EHD USEONLY OWNER ID# II <br /> CASE <br />* COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATIDNOWNER FILE <br /> CHECKIF OWNER CURRENT Ly ON FILE wrrNEHD <br /> BUSINESS <br /> OWNER NAME PHONE <br /> First M! I Last o" <br /> [BUSINESS NAME(If C#ffefenf from Owner Name) I� SOC Sec Or Tax ID# <br /> OWNER HOME ADDRESS 'Z <br /> .Il <br /> CITY /� <br /> iJ CA STATE Zip <br /> OWNER MA uNG ADDRESS(If differentfrom Owner Address) I Attention or Care of <br /> MAILING ADDRESS CITY STATE ZIP <br /> TYPE OF OWNERSHIP: .i <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY 11 COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILJTY ID#: COAWNER ID#: II ACCOUNT ID#: <br /> COMPLETE THE FOLLOWING BUSINESS FACILITY INFORMATION: <br /> IS this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YE No ElIs this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? .I: YES ❑ No ❑ <br /> BUSINESSIFACiuTY NA E is will be the EIvstNEss;WvEon the HEALTH P RM1T) <br /> C f <br /> FACILITY ADDgESS{If�Fa is a Moer �F [1rXrror F UErrrc se the ft BUSINESS PHONE <br /> 6/ G/ rS (r�T I' e# I <br /> CITY(IfFAauryi9�&LEFOOD UmrorFOOD VENrcLEusetheCnmmmsAeyGm) Sj�jTEA17 7 ZIP �i <br /> (/C/ <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEYT KEY2 <br /> MAILING ADDRESS for Health PenTlit(If DIFFERENT from Facility Address) Attention or Care Of <br /> MAILING ADDRESS CITY I STATE ZIP <br /> .h <br /> SEC Cone: COMMENT: �g <br /> for fees and charges: OWNER <br /> iL0 FACILITY/BUSINESS ❑ <br /> IRILLING,AND COMPI.IANCR AclnvowLEDGmrNT; 1, the undersigned Applicl�nt, certify that I am the Owner, Operator, or Authorized Agent of.this <br /> Business,and I acknowledge that all PERMIT FEES,PENALTIES,ENFORCEMEmi.CHARGES and/or HOURLY CHARGES associated witht <br /> his operation will be <br /> billed to me at the address identified above as the for this site. I also certify that all information provided on this application is true <br /> and correct; and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL haws and Re ulations. II <br /> APPLICANT NAME: SIGNATURE: <br /> Please Print <br /> TITLE: DATE I DRNER'S LICENSE# <br /> ...(PHOTOCOPY 1jFQUIRED) <br /> Approved By Date Accounting Office Processing Completed By Date.l <br /> A PROGRAM{EHD 48-02-034 Pink}or WATER SYSTEM{EHD 46-02-003)form mllsf be completed for Each EHD regulated operation at II Is except <br /> UST Program(Use SWRCB forms) <br /> EHD 48-32-035 <br /> 10/9/2003 Masterfile Record-Green <br />