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SAN JOAF_`N COUNTY ENVIRONMENTAL HEALTH r `9ARTMENT <br /> 1'OtASTERFILE RECORD INFORMATION F044 <br /> SHADED SEC17ONS FOR EHO USE ONLY OWNER ID# ©� f CASE# <br /> OWNER FILE <br /> COMPLETE THE FOLLOIMNG BUSINESS OWNER INFORMATION; CNECKIF OWNER CuIZRENTLYONF7LE41?TNEHD <br /> BUSINESS PHONE <br /> OWNER NAME First MI Cast <br /> II <br /> LMAJLING <br /> E(if different frnrrt Owner Name) Soc Sec Or Tax tD# <br /> � o Tm �vT' <br /> ME ADDRESS ' 017- <br /> STATE ZIP Sao <br /> G DRESS (1f different from owner Address) Attention or Care of <br /> ESS CITY STATE ZIP <br /> TYPE OF OWNII ,RSHIP: <br /> CORPORATION L! INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY 12f COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> CO-OWNER ID#: ACCOUNT ID#: <br /> FACILITY ID#,: <br /> COMPLETE TNEFOLLOWING BUSINESS FACILITY INFORMATION; <br /> I EI <br /> f Fthii, <br /> NEW`Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No ❑ <br /> I €I. <br /> k EXISTING Business LOCATION but a NEW TYPE of regulated Business? 1 ES ❑ No ❑ <br /> 1 ih <br /> I $USENE351F��11�AMI= E5 will be the Bu5rNe55 NAME on the HEALTH PERMIT) <br /> *Yw✓' f l/ S <br /> FACILITY AmR QfFAcrLrryIsaMoarL9 ooDUNITor VENrCr�use the Commisv+RvAMREssl BUSINESS PHONE <br /> lobo i� s <br /> Suite#1 <br /> h STA ZIP f <br /> street Street Ugrne Street Tvne <br /> CITY(If Faat t css Mosrr F000 UNtr or F000 Vert+aA use the Coa®mS56xY�nc) � [' f 0 <br /> J <br /> f BOARD OF SUP, <br /> U lI RVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> Illk MAILING ADDRESS for Health Permit(If DIFFERENTfrom Facility Address) Attention or Care Of <br /> €I <br /> MAILING AD61RESS CITY STATE ZIP <br /> SIC CODE; APN ft: COMMENT: <br /> f <br /> for fees and charges: OWNER ❑ FACILITY/BUSINESS ❑ <br /> �r <br /> : 1, the undersigned Applicant, certify that I am the Owner, Operator, or Authorized Agent of this <br /> Business,andh acknowledge that all PERMq FEES,PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation will be <br /> billed to me attlte address identified above as the ACCOUNTADDRF.SS for this site. I also certify that all information provided on this application is true and <br /> correct; and that all regulated activities will be performed in accordance with all applicable SAN JOAQuIH CouNTY Ordinance Codes and/or Standards <br /> and STATE anA/or FEDERAL Laws and Re ulations. <br /> II <br /> APPLICANT NAME: SIGNATURE: <br /> Please Print <br /> TITLE: DATE DRIVER'S LICENSE# <br /> .F <br /> I <br /> Approved By C,� Date y� O Accounting Office Processing Completed By Date <br /> A PROGRAM{EHD 48-02-034 Pink)or WATER SYSTEM{EHD 46-02.003)form mils t be completed for each EHD regulated operation at this except <br /> UST Program I{Use SWRCB forms) <br /> EHD 48-02-035 Masterfile Record-Green <br /> 10!912003 <br /> t .. <br />