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REV. 04/09/99 <br /> • SAN JOAQUIN COUNTY .. PUBLIC HEALTH SERVICES 8 ENVIRONMEN--&- HEALTH DIVISION <br /> rf MASTERFILE RECORD INFORMATION <br /> DATE / OWNER ID Y CASE r <br /> OWNER FILE <br /> COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION: CHECKIF OWNER CURRENrLYON}FILE WITH EHO ❑ <br /> BUSINESS OWNER NAME �v 1 / / Ef/J� L�ro4 z /' PHONE g�l L t�� 7 d <br /> ust M1 Last <br /> BUSINESS NAME(it DIFFERENT from Bus,ness NamSoc Sic/TAX ID Y <br /> OWNER HOME ADDRESS / L9 <br /> Clry l� �, �� �, 5TA1E LP <br /> OWNER MAILING ADDRESS (p DIFFERENT from Owner A ss) .� Attention:or Care of (opMonaA <br /> i <br /> Mailing Address City Slatle,� Zip <br /> (( ; I <br /> TYPE of OwNEissHiP: <br /> CORPORATION 4 INDIVIDUAL PARTNERSHIP LOCAL AGENCY COUNTY AGENCY STATE AGENCY FED AGENCY Rt OTHER ffi <br /> FACILITY FILE <br /> FACILITY ID# CROSS REF IDM I I ACCOUNT ID# <br /> COMPLETE THE FOLLOWING BUSINESS FACILITY INFORMATION: <br /> BUSINESS/FACILITY NAME(THIS vnu M THE NAME ON THE HEALTH PERMIT <br /> FACILITY ADDRESS OR COMMISSARY ADDRESS _ SUITE Y BUSINESS PHONE <br /> CITY OR COMMISSARY ADDRESS /, � STATE_ Lr ; <br /> BOARD Of SUPERvISOR DISTRICT LOCATION CODE KEY 1 KEY2 <br /> HEALTH PERMIT MAIUNG ADDRESS(if DIFFERENT from Facility Address) Anenfion:or Care OI(opflona0 <br /> Mailing Address City STATE LP <br /> SIC CODE APN COMMENT <br /> ACCOUMADDRESS for fees and charges OWNER FACILITY)BUSINESS <br /> BILLING ANI) COMPLIANCE ACKNOWLEDGMENT: I, the undersigned Applicant, certify that I am the Owner, Operator, or <br /> Authorized Agent of this Business,and I acknowledge that all PEMWIT FEES, PENALTIES, ENFORCEMENT CHARGES and/or HOURLY <br /> CHARGI..S associated with this operation will be billed to me at the address identified above as the ACCOUNTAIM)RESS for this site. I <br /> also certify that all information provided on this application is true and correct;and that all regulated activities will he performed <br /> in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or FEDERAI. Laws <br /> and Regulations. <br /> APPLICANT NAME(Please Print) SIGNATURE <br /> 1 Approved <br /> "roved By Date Accounfing Office Processing Completed By Date <br />