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SAN JOAI&COUNTY ENVIRONEIENTAL HEALTH *ARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> F <br /> SHADED SECTIONS FOR <br /> EHD USE ONLY <br /> OWNER FILE <br /> COMPLETE THEFOLLOW/NG BUSINESS OWNER /NFORMA77ON: _ CHECK lF OWNER CURRENTLYON Fite wiTrlEHD <br /> PHONE <br /> "NAMf <br /> First M1 Last <br /> wm0 er Name) l J SO;Sec orTax ID# <br /> S ___ <br /> CITY l. �O� STAT ZIP �S�Z <br /> OWNER MAILING ADDRESS (HdiRerent Yromowner Address) <br /> Attention or Care of <br /> STATE ZIP �. <br /> MAILING ADokESS CITY <br /> TYPE OF OWNERSHIP: <br /> CORPORATION❑ INDIVIDUAL PARTNERSHIP 11 LOCAL AGENCY❑ COUNTY AGENCY El STATEAGENCY❑ FED AGENCY OTHER❑ <br /> FACILITY FILE <br /> 00)Slo AccouNTID#: <br /> FACILITY ID#: CO-OWNER ID�: <br /> COMPLETE THEFOLLOW/NG BUSINESS FACILI NFORMA770N: <br /> YES- No <br /> Is this a NEW BUSIneS9 LOCATION Or VEHICLE not preVIOUSIy regulated by the ENVIRONMENTAL HEALTH <br /> ❑ <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ NO"6 <br /> BUSINESSIFACILITY NAME(This will be the us,NE Eon the H LTF{PE`R I IT) <br /> ` lY d SINESS ON <br /> FACILITY ADDRESS(K FAGLT'is a MOSICEFOOO UN FOOD VEH=Eu"then A DRESS) PHONE <br /> C NESS nE <br /> E Suitep <br /> go Z <br /> STATE IP Q S��— <br /> CITY(if FaclurYls LE FOOD UNRaf F000VENIDLE use theCOMMISSA Y rnY) <br /> C AGn <br /> KEvt KEY2 <br /> BOARD OF SUPERVISOR DISTRICT IACATION CODE <br /> MAILING ADDRESS for l'/Bal//1 Pt9F7TTlflH DIFFERENrtrem FacilityAddressJ <br /> Attention or Care Of <br /> STATE ZIP <br /> MAILING ADDRESS CITY <br /> SIC CODE: <br /> APN fk COMMENT: <br /> for fees and charges: OWNER FACILITY/BUSINESS ❑ <br /> HIT I IN(-, AND f'rntPt I �rF Arkamvl FnrclFVT: 1, the undersigned pp!cant, certify that I am the Owner, Operator, or Authorized Agent of this <br /> Business, and I acknowledge that all PEBMIT FEES,PRxALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation will be <br /> billed to me at the address identified thaa above as theE r PENAL <br /> c for this site. I also certify that all information provided on this application is true and <br /> correct; and that all regulated activities will be performed in accordance with all applicable SAN JOAQutN COUNTY Ordinance Codes and/or Standards <br /> and STATE and/or FEDERAu Laws and Regulations. <br /> SIGNATU <br /> APPLICANT NAME' /l0,1 <br /> -- I- <br /> P/ease Flint DATE O DRIVER'S LICENSE# <br /> !� <br /> TITLE: 01 <br /> L Ly <br /> APP ,�ey I Date <br /> II Accounting om Processing.. <br /> — ___,e.el w.. 7�i I Date '112 E) <br /> / _ <br /> A PROGRAM{EHD 48-02-034 Pink}or WATER SYSTEM{EHD 48-02-0031 form trust be completed for each EHD regulated operation at this LDCATION <br /> except UST Program(Use SWRCB forms) Masterfile Record-Green <br /> EHD 48-02-035 <br /> 101912003 <br />