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I t- _ <br />REV. 02/16/00 • <br />SAN JOAQUIN COUNTY � PUBLIC HEALTH SERVICES ' ENVIRONMENTAL HEALTH DIVISION <br />MASTERFILE RECORD INFORMATION <br />DATE <br />OWNER FILE <br />COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATmnf, CHECKIF OWNER CURRENTLY ON FILE WITH EHD n <br />BUSINESS <br />OWNER NAME <br />FACIUTY ADDRESSOROR COM"I SARY7Y ASDDVrDDR�ESSS�`^� <br />1 I I r ?v r/ 1 <br />SUITE # <br />BUSINESS PHONE <br />CITY OR COMMISSARY ADDRESS <br />LJ <br />PHONE <br />ZI <br />U/LJ <br />Fk31 <br />M! <br />LOCATION <br />Last <br />KEYS <br />BUSINESS NAME (ifDIFFERENT from Business Name) <br />KEY2 <br />SOC SEC I TAX ID # <br />OWNER HOME ADDRESS <br />Mailing Address City <br />STATE <br />city <br />SIC <br />STATE <br />ZJP <br />OWNER MAIUNG ADDRESS ( If DIFFERENT from Owner Address) <br />COMMENT <br />Attention: or Care of (optional) <br />Mailing Address City <br />Staff <br />I Zip <br />TYPE OF OWNERSHIP' <br />CORPORATIONINDNIDUAL PARTNERSHIP LOCAL AGENCY <br />COUNTY AGENCY STATE AGENCY FED AGENCY OTHER <br />FACILITY FILE <br />FACILITY ID # 00 (Li6 01 CROSS REF ID# I ACCOUNT ID # AiQ0 02 ` 7y <br />COMPLETETHEFOLLOWING BUSINESS FACILITY INFORMATION- <br />BUSINESSIFACILITY N E (THIS wILL BE THE NAME ON THE HEALTH PERMIT) <br />5 <br />FACIUTY ADDRESSOROR COM"I SARY7Y ASDDVrDDR�ESSS�`^� <br />1 I I r ?v r/ 1 <br />SUITE # <br />BUSINESS PHONE <br />CITY OR COMMISSARY ADDRESS <br />$ ATE <br />ZI <br />U/LJ <br />BOARD OF SUPERVISOR <br />LOCATION <br />KEYS <br />KEY2 <br />HEALTH PERMIT MAILING ADDRESS (if DIFFERENT from Facility Address) <br />Attention: or Care Of (optionao <br />Mailing Address City <br />STATE <br />ZIP <br />SIC <br />APN <br />COMMENT <br />' ACCOUNrADDRESS-for fees and charges OWNER FACILITY/BUSINESS <br />BILLING AND COMPLIANCE ACKNOWLEDGMENT: I, the undersigned Applicant, certify that I am the Olaner, Operator, or <br />Authorized Agent of this Business, and I acknowledge that all PE•RAHT FEES, PENALTIrS, ENrORCEAtrNT CIIARGu and/or. Houl?LP <br />CIrARGr.S associated with this operation will be billed to me at the address identified above as the Aceouiyrlf nRrss for this site. I <br />also certify that all information provided on this application is true and correct; and that all regulated activities will be performed <br />in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or FEDERAL haws <br />and Regulations. <br />APPLICANT NAME (Please Print) I SIGNATURE <br />TITLE <br />Approved By Date Accounting Office Processing Completed By Date <br />