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* ,11 SAN JOAQUIN COUNTYUBLIC HEALTH SERVICES • ENVIRONM AL HEALTH DIVISION <br /> DATE0 EE:: FORM (EH 0015(REVISED 1O/02196) <br /> :ZE— MASTERFILE RECORD INFORMATION <br /> SHADED SECTIONS FOR EHDUSEONLY OwNERID#: SE# <br /> OWNER FILE <br /> COMPLETE THEFOLLO.WING BUSINESS OWNER../NFORMAT/ON:. .. CHECKIF OWNER CURRENTLYONF/LEW/THEHD <br /> ..... ..................... ................ ...................... ..---------........................................................................................................................ <br /> BUSINESS OWNER : PHONE <br /> NAME <br /> . ------------------------------------------ <br /> ---—_ __—_--__----_-------------------- <br /> ...................................................................Firsti <br /> .......................................!N(...............................................Oast...................................... <br /> BUSINESS NAME(If different from Owner Name) i SOC SEC 1 Tax ID# <br /> OWNER HOME ADDRESS DRIVER'S LICENSE# <br /> STATE ZIP <br /> OWNER MAILING ADDRESS ifDIFFEREA/Tfrom Owner AddressAttention:or Care of(option/) <br /> Mailing Address City State Zip <br /> TYPE OF OWNERSHIP: <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ QTHER❑ <br /> FACILITY FILE <br /> FACILITY ID# CROSS 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 ExiSTING Business LOcAT1oN but a NEW TYPE of regulated Business? YES ❑ No ❑ <br /> BUSINESS/FACILITY NAME(THIS WILL BE THE NAME ON HEALTH PERMIT) <br /> FACILITY ADDRESS(IF FACILITYIS A MOBILEFOOO UNITOR FOOD VEHICLE USECOMMISSARY ADDRESS) SUITE# BUSINESS PHONE <br /> i <br /> CITY IF FACILITY ISA MOBILE FOOD UNITOR FOOD VEHICLE USE COMMISSARY ADDRESS CITY) STATEr i Zip <br /> -BOARDOP SUPERVISOR DISTRICT .: LOCATION CODE KEYi. . - KEY2 <br /> Mailing Address for Health Permit ifDIFFEREArrfrom Facility Address Attention:or Care Of(optional) <br /> i Mailing Address City ! STATE i Zip <br /> SIC CODE APN# COMMENT: .I <br /> THIRD PARTY BILLING INFORMATION: Complete if Billing Party is different from Business Owner Identified above. <br /> .................................................................................................... ......................................................................................................... <br /> BUSINESS NAME Attention:or Care Of (optional) <br /> Mailing Address PHONE <br /> CITY STATE ZIP <br /> A=te -NTAnnREss for fees and charges OWNER ❑ FACILITY/BUSINESSTHIRD PARTY BILLING ❑ <br /> BILLING AND COMPLI.aNCE ACKNOW-LEDGMENT: I, the undersigned Applicant, certifv that I am the Owner, Operator, or Authorized <br /> Agent of this Business, and I acknowledge that all PERVIT FEES, PENALTIES, ENFORCE�LIENT CHARGES and/or HOURLY CHARGES <br /> associated with this operation will be billed to me at the address identified above as the ACCOUNTADORESS 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# <br /> _(PHOTOCOPY REQUIRED) <br /> Approved By Date Accounting Office Processing Completed By Date <br />