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SAN JO..JIN COUNTY ENVIRONMENTAL HEALTH L .-ARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> SHADED SECTIONSFOR EHD USE ONLY OWNER I # CASE# <br /> OWNER FILE <br /> COMPLETE THEFOLLOW/NG BUSINESS OWNER INFORMATION.- CHECK IF OWNER CuRREN7LYcNFiLE w1TH EHD❑ <br /> BUSINESSB O PHONE: <br /> OWNER'S NAME Z 3 '4 —34_<-0 <br /> First MI Last <br /> BUSINESS NAME(If differentfrom Owner Name) C Soc Seo or Tax ID# <br /> OWNER'S HOME ADDRESSC)�' /QO <br /> CITY A E ZIP SZO <br /> OWNER'S MAILING ADDRESS(If different from Owners Address) Attention rC.re of <br /> MAILING ADDRESS CITY STATE ZIP <br /> TYPE OF OWNERSHIP: <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY FED AGENCY❑ OTHER❑ <br /> FACILITY FILE G6lzs� / 0 C Lf LF -56- <br /> FACILITY ID#: .q_;zCO-OWNERID#: ACCOUNTID#: <br /> COMPLETE THEFOLLOW/NG BUSINESS FACILITY/NFORMAT/ON: <br /> Is this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES NO ❑ <br /> Is this an EXISTING Business LOCATION but NEW TYPE Of regulated Business? YES ❑ NO <br /> BUSINESs/FACI ITY NAME(This will be the BuslNEssNAnrEon the HEAL/7H PERMIT) <br /> FACILITY ADDRESS(MFACamla a Mo rzEFooa UNror FOOD✓EHicLEuse the COMMISSARY ADDRESS I BUSINESS PHONE <br /> ZiC% ? /-�, -f- '2j <br /> Sude# <br /> CITY(If^FAauTYls.MostLE FOOD UMTor FOce VEHIOLE use the COMMISSARY CITY) STATE ZIP <br /> BOARD OF SUPERVISOR DISTRICT LOCATIONCODE KEY1 KEV2 <br /> MAILING ADDRESS for Health PermY1(If DIFFERENTfrom FacdityAddres.) Attention orCam Of <br /> �( <br /> �,17Y Lr /[ i2b <br /> MAILING ADDRESS CITY STATE ZIP <br /> SIC CODE: APN11: 3102, COMMENT: <br /> ACCOUNTADDRESS for fees and charges: OWNER ❑ FACILITY/BUSINESS ❑ <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I <br /> acknowledge that all PERMIT FEES, PENALTIES, ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation will be billed to me at the <br /> address identified above as the AccoUNTADDRESS for this site. I also certify that all information provided on this application is true and correct;and that all <br /> regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or FEDERAL <br /> Laws and Regulations. <br /> APPLICANT'S NAME: SIGNATURE: <br /> Please Print <br /> TITLE: DATE DRIVER'S LICENSE# <br /> PHOTOCOPY REQUIRED <br /> Approved By Data Accounting Office Processing Completed ByTT I Date <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 LOCATION <br /> except UST Program(Use SW RCB forms) <br /> EHD 48-02-035 ���� Masterfile Record-Green <br /> 11/27/07 v __ 7 I/_ /I( <br />