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SAN JOAQUIN COUNTY 'UBLIC HEALTH SERVICES • ENVIRONMT "AL HEALTH DIVISION <br /> FORM (EHDDIS(REVISED10102196) <br /> DATE MASTERFILE RECORD INFORMATION <br /> SINOEOSECnONSFOREHD USEONLY OWNER ID# CASE# <br /> OWNER FILE <br /> COMPLETETHEFOLLOW/NG BUSINESS OWNER INFORMAT/ON: CLE'CKW OWNER CDRweNTLY0NFXEWMEHO El <br /> ..........................................................................................................................................................................................._..........................................._............................................................... <br /> ; <br /> euslNEss OWNER ' PHDrE <br /> ` <br /> NAME `---------------- <br /> ..................................................................Ei!.*.t......................................_MS...................................__AWBd._._.....__..........._.......i— i <br /> 81.191NEss NAME(If diKeronttromOWnar Nana) Soc SEC I TAK ID f <br /> ORNER HOME ADDRESS u,dYER'a La:ENaE f <br /> City i STATE LP <br /> OpmERMAIuNOAooREsa d'O/FFERENTho/n OWnerAddreas AMRItion:wCarsof(opilonal) <br /> Mailing Address City staff ! Zip <br /> TYPE OF OWNERSHIP: <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FEO AGENCY❑ QTHER❑ <br /> r <br /> FACILITY FILE <br /> FACILITYIDfCROSS REF ID# ACCOUNT ID.# ' <br /> COMPLETETHEFOLLOW/NG BUSINESS FACILITY INFORMATION: <br /> Is this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DIVISION? YES ❑ No ❑ <br /> Is this an EmSTING Business LOCATION but a NEW TYPE of regulated Business? Y6 ❑ NO ❑ <br /> BusimEsa/FAcIuTY NAME(THIS WILL BE THE NAME ON HEALTH PERMIT) <br /> .�cgylnc91n L22 <br /> FACIL"ADDRESS#FFACIL/TY/SA MoRAEFOOO UMTOR FOOD VEH/ usECOIOassARYAODRES9) SMTEf aDpalaa PHONE <br /> CRY/F FACI(1TY/sAMOB/1EF000 tM I VBIIXE usECOMMISaARYADDRESS CM SCAM <br /> 'C IC�� X14 -(]CfJ`JJ <br /> BOA RDOFSUPERVISORDISTRICT.. : LOCATIONCOOf KEY1 RE`2 <br /> Mailing Address torHealth Parmil ii DIFFERENThon FacifilrAddrema Attention:or Care Of(ophonal) <br /> Mailing Address City STATE LP <br /> SIC CODE APN f. . .: COMMENT: <br /> THIRD PARTY BILLING INFORMATION: COmplete if Billing Party is different from Business Owner Iden above. <br /> ..........................................................................................................................................................................................------------.-----....-----.-----................................................................. <br /> ............ <br /> i aUMNESB NAtE i Attention: rCars Of(opAbnal) <br /> Mailing Address PIaNE <br /> CITr i STATE ZIP <br /> ACCOJ/MfLADDRFC.R for fees and charges OWNER ❑ FACLITY/BUSINESS. THIRD PARTY BILLING ❑ <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant, certify that I am the Owner, Operator, or Authorized <br /> Agent of this Business, and I acknowledge that all PERMIT FEES, PENALTIES, ENFORCEMENT CHARGES and/or HOURLY CHARGES <br /> associated with this operation will be billed to me at the address identified above as the ACCOUNTADDRESS for this site. I also certify <br /> that all information provided on this application is true and correct; and that all regulated activities will be performed in <br /> accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or FEDERAL Laws and <br /> Regulations. <br /> PLEASE PRINT <br /> APPLICANT NAME SIGNATURE <br /> TITLE DRIVER'S LICENSE f <br /> (PHOTOCOPY REQUIRED) <br /> Approved By Data" Aeeounano Office Processing Completed By Date t16- y yp q' <br />