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WPMSAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> PM MASTERFILE RECORD INFORMATION FORM <br /> q��p�Pt,AAUy`rG;�r(Q0�$,3 20116 <br /> �'•1I1f1V"MLNI 9 <br /> CALTH ONLY OWNER I D# DI11vv� g'6� OASE# <br /> PERMIT/SERVICES OWNER FILE <br /> COMPLETE 7HEFOL1 OWING BUSINESS OWNER/NFORMAT/ON.' CHEcxiF OWNER CuRREN YON WITHEHD❑ <br /> BUSINESSVM1 11 �//� PHONE: <br /> OWNER'S NAME ` . —C J ) <br /> D*TF,irls�tMI Last J <br /> BU31NESs NAME(If different from Owner Name <br /> <br /> _ <br /> CITY -Jl T E ZIP <br /> OWNER'S MAILING ADDRESSdiffemntfrom Owner's Addresa) Attention orCare of <br /> a1' _ <br /> MAILI DRESS TY TIA�E <br /> TYPE OF OWNERSHIP' <br /> CORPORATION❑ INDIVIDUALV PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY OTHER❑ <br /> FACILITY FILE <br /> FACILITYID#: W� CO-OWNER ID#: ACCOUNTID#: t�(� <br /> COMPLETE THEFOLLOW/NG BUSINESS FACILITY/NFORMATI w <br /> IS this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES NO ❑ <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ NO <br /> BUST Ess/FACILITY NAME(ThiA will be t US/NESS)YAMEon the HEALTH PERMIT) <br /> Y W <br /> FACILITY ADDRESS(If 01Lmis OaILEFOQOUNITOr F OO VEHICLEUSS the COMMISSARY AOORESS) BUSINESS PHONE <br /> (& S- 'n N cska 11 .5213 <br /> Suite# <br /> CITY{If FAo I ahfoe;LE FOOD UN,Tor FOOD VEMCLE use the COMMIssARY Cr-Y STATE ZI <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEYI KEY2 <br /> LIN ADD SS f0/fiepIth PqrTl.t(If D/FFERE from Faci/ityAddress) Attention or Care Of <br /> MAILING ADDRESS CITY $ T <br /> SIC CODE: APN#: COMMENT: <br /> ACCOUNTADD/D EESSfor fees and Charges: OWNER FACwTY/Bus[NESS ❑ <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business.and <br /> 1 acknowledge that all PERMIT FEES, PENALTIES, ENFORCEMENT CHARGES and/Or HOURLY CHARGES associated With this Operation will be billed t0 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 <br /> all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or <br /> FEDERAL Laws and Regulations. <br /> APPLICANT'S NAME: �QmSIGNATUR <br /> TITLE: <br /> lease Print <br /> DATE _ DRIVER'S LICENSE# <br /> (((���,,�,, MPHOTOCOPY RE GU <br /> Approved By yl y I o Dete 1. Accounting Office Processing.Completed By Deb // //0 <br /> A PROGRAM((EHD 48-02-034 Pink)or WATERSYSTEM(EHD 46-02-003)form must be completed for each EHD regulated operation at this LOCATION <br /> except UST Program(Use SWRCB forms) <br /> EHD 48-02-035 Masterfile Record-Green <br /> 8119/08 <br />