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SAN JOAr"-IIN COUNTY ENVIRONMENTAL HEALTH�PaPARTMENT � <br /> �ASTERFILE RECORD INFORMATION FO eldl <br /> SHADED SECTIONS FOR END USE ONLY OWNER ID# OQ 5 CASE# <br /> OWNER FILE <br /> OMPLETETHEFOLLOWING USINESS NFORMATION' CtiECKtF OWNER CuRRFnl7iyoNFrcEwrrt/EHD <br /> ❑ <br /> BUSINESS PHONE: <br /> OWNER'S NAME Mf Last <br /> First BUSINESS NAME(If diffemntfrom owner Name) SDC Sec arTax ID# <br /> C1 d ��T1� <br /> OWNER'S HOME ADDRESS 3 Q 7QG✓i��' �ir Arc rz-- 1./A <br /> CITY efi STATE ZIP SJ <br /> QWNER'S MAILING ADDRESS(If dif Tnt from ner s Address) Attention orCare of <br /> MAILING ADDRESS CITY $TATE ZIP, <br /> i <br /> TYPE OF OWNERSHIP: <br /> CORPORATION❑ INDIVIDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID#: CO-OWNER ID#: ACCOUNT ID#: <br /> l <br /> THE FOLLOW&WRM <br /> IS this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES C1 NO 13 <br /> Is this an E)mSTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ❑ <br /> G BUSINESS/FACILrr2y AME(This will be the HvmNES4NAMEon the HEALTH PERMIT) <br /> I <br /> FACIt.IIY ADDRESS(If FArlttrr is a Mtasru- UnnTOr FOD VEKaEuse the COMMISSARY AmREss) BUSINESS PHONE <br /> Z'4 Z S— Yo /I Y/F <br /> Suite# <br /> CITY(If FACILnY rs a MOBILP FOOD UNrror FOOD WHrcLE use the Cn1nncc4 Y M) STATE ZIP <br /> l BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEYZ <br /> MAILING ADDRESS for HeaII/T Permitif DIFFI=Rarfrom FadlityAddre-s) Attention DrCare of <br /> MAILING ADDRESS CITY STATE ZIP <br /> SIC CODE: APN#: COMMENT: <br /> i 4CC01MM 4DORE_C_Sfor fees and charges: OWNER ❑ FACILITY/BUSINESS ❑ <br /> r <br /> BII i iNr:ANn Comm IANnr Or.KNOI& FnGMENT: 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 and/or HOURLY CHARGES associated with this Operation will be belled t0 me at the <br /> address identified above as the AcrQUNTAnDREss for 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 Rectulations. <br /> I <br /> AYP <br /> LI NT'5 AM I NATURE' <br /> I Please Pnnt <br /> TYLE: DATE DRIVER'S LICENSE# <br /> IApprored By Date Accounting Office Processing Completed By .Date <br /> 11 <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 OCA130N except UST Program(Use SWRCB forms) <br /> EHD 48-02-035 Masterfile Record-Green <br /> 8/19/08 <br />