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SAN JOIASTERFILE <br /> N COUNTY ENVIRONMENTAL HEALTARTMENT <br /> RECORD INFORMATION FORM <br /> SHADED SECTIONS FOR EHD USE ONLY OWNER ID# b�O(�� CASE# <br /> OWNER FILE <br /> COMPLETE THE FOLLOWING BUSINESS OWN ER INFORMATION: CHECKIF OWNER CURRENTLY ON FILE KITH EHD <br /> BUSINESS �� PHONE <br /> OWNER NAME <br /> First M/ Last / 7 <br /> BUSINESS NAME(If different from Owngr Name) Soe Sec orTaX ID# <br /> OWNER HOME ADDRESS <br /> CITY STATE ZIP <br /> OWNER MAILINGRESS (if different from Owner Address) Attention or Care of <br /> 6ZD ' X06 <br /> MAILING ADDRESS CITY O ST ZIP S Z 3 <br /> TYPE OF OWNERSHIP: <br /> CORPORATION INDIVIDUAL❑ PARTNERSHIP El LOCAL AGENCY COUNTY AGENCY El STATE AGENCY FED AGENCY❑ OTHER❑ <br /> ,{^ FACILITY FILE <br /> FACILITY ID#:y- gpZ. CO-OWNER ID#: ACCOUNT ID#: <br /> COMPLETE THE FOLLOWING BUSINESS FACILITY INFORMATION: <br /> IS this a NEN/Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES y� NO ❑ <br /> Is this an EXISTING Business LOCATION but a NEW TWE of regulated Business? YES ❑ No <br /> BUSINESS/FACILITY NAME(Thi will"the "" <br /> N7an 1t�e�HEALTH PERM <br /> D r ^ N c <br /> FACILITY ADDRESS(If FtaI is a Moeo.E FOOD UNrror FOOD Vaiy athe C, n I sNzY Annems ^BUSINESS/PHONE <br /> Suite# /t� ' 7 J✓ J <br /> CITY(if FAcruTrisa©BaEFDOD UMor FooD VEwCLE use the L=WSwvenin STA ZIP <br /> BOARD OF SUPE rIR'-VISOR DISTRICT LOCATION CODE KEY1 KEY2ED <br /> _MAI / 5 <br /> LLMG ADDRESS for Health POnnit(If DIFFERENTfmm FaulrlyAdomss) Attention or Care Of <br /> Y� v <br /> MAILING ADDRESS CITY $ ATE ZIP <br /> SIC CODE: APN#: D 2-0 CoM fr% <br /> for fees and charges: OWNER ❑ FACILITY/BUSINESS ❑ <br /> BUI.INr AND Cfmfer IANrP ArKNo\yr PnrmxivT: I, the undersigned Applicant, certify that I am the Owner, Operator, or Authorized Agent of this <br /> Business, mud I aclmowledge that all PERMW.FEES,PENALTIES,ENFORCEDfENT CILIRGES and/or HOURLY CH"GES associated with this operation win he <br /> billed to me at the address identified above as the AccouNTADDRpss 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 JOAQUIN COUNTY Ordinance Codes and/or Standards <br /> and STATE and/or FEDERAL LawsandRe ulations. / <br /> APPLICANT NAME: ,u � �I SIGNATURE: <br /> Please PrintTITLE; DATE DRIVER'S LICENSE# <br /> (PHOTOCOPY RFOUIRFn) <br /> Approved ByILA— I Date LLL Accounting Office Processing Completed Bykc Date 4 I <br /> A PROGRAM(EHD 46-02-034 Pink)or WATER SYSTEM(EHD 46-02-003)form musf be completed for each EHD regulated operation at this l OCATION except <br /> UST Program(Use SWRCB forms) <br /> EHD 48-02-035 Masterfile Record-Green <br /> 10/9/2003 <br />