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SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH PcPARTMENT <br /> i <br /> ��STERFILE RECORDINFORMATION FCS <br /> SHADED SEC77ONS FOR EHD USE ONLY OWNER ID# CASE# q <br /> I 'II <br /> OWNER FILE <br /> ONPLETETHEFOLLOWING BUSINESS QW N E RNFORMATION' II CHECKIFOWNER CURRII YONFILEWrrHEHD❑ <br /> BUSINESS PHONE'I <br /> OWNER'S NAME <br /> First M! Last <br /> BUSINESS NAME(If differentfrom Owner Name),p / �+ � SOC Sec orTax ID# � <br /> / Z-C7Y✓ W(�;/L C�t%SS /^/o <br /> I� <br /> OWNER'S HOME ADDRESS -Z 9 y <br /> CITY STATE ZIP:1 S 9 <br /> OWNER'S MAILING ADDRESS (If difi`ereatfivmOwner's Address) Attention orCare of I� <br /> �I <br /> MAILING ADDRESS CITY STATE ZIP II <br /> TYPE OF OWNERSHIP: <br /> CORPORATION❑ INDIVIDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED 1AGENCY❑ OTHER❑ <br /> II <br /> FACILITY FILE <br /> FACILITYID#: Q CO-OWNER ID#: I' ACCOUNT ID <br /> Is this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES 11 No ElI!. <br /> Is this an ExItsTING Business Lorr►TIoN but a NEW TYPE of regulated Business? YES ❑ No ❑ <br /> BUSINESS/FACILITY NAME(This will be the BUSINESSNAMFon the EALTH PERMIT) y11 <br /> lr'C>A1 — <br /> FACILITY ADDRESS(If Fa is a MOsrceFooD UNrror Fad VE/ffL "'th I ) BUSINESS PHONE <br /> � <br /> . iia Sutfe# <br /> CITY{If Facturris a MostLE�O��oD VEHICLE use the rnimmmsnRY rirv) gTgTE ZIp�,1},r <br /> /�' <br /> IIS li <br /> BOARD OF SUPERVISOR DLSTRICT LOCATION CODE KEY1 KEY2Ir <br /> MAILING ADDRESS fOr Health PerM&(1f RIFFERENTfrom FadlityAddreSs) I Attention orCare Of <br /> II <br /> MAILING ADDRESS CITY STATE ZIP II_ <br /> 1� I <br /> SIC CODE; APN#: COMMENr: j <br /> ACMI EADD ESS for fees and charges: OWNER[ ❑ FACILITY/BUSINESS ❑' <br /> II ll <br /> BILLING AND COMPuANrF,UKbInwl FnrmFNT: 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, PENAL17ES, ENFORCEMENT CHARGES and/or MOURLY CHARGES associated With this operation Will be billed to me at the <br /> address identified above as the ArCOUNT AnnRFcc for this site. I also certify tAt 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 /> i <br /> PPLICANT'S AME' SIGNATURE' I� <br /> Please Print <br /> (PHOTOCOPY REQUITRED) <br /> TITLE: DATE DRIVER'S LICENSE# <br /> Is i <br /> Approved By[�. Accounting Oabe Processing Completed By Da,6 j <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 nreTTnN except UST Program(Use SWRCB forms) <br /> EHD 48-02-035 I Masterfile Record Green <br /> 8/14/08 <br />