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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES-ENVMUNMENTAL HEALTH DIVISION <br /> MASTERFILE RECORD INFORMATION FARM ,i{EH 00 15(flovised 6194)} <br /> New Facility IF Under Construction ? ;� Data <br /> HADED SECTIONS FOR LOCAL USE ONLY OWNER FILE INFORMATION y <br /> . ..OWNER <br /> AISI: # CHECK I34X tF OWNtf ON FILE <br /> Please complete the following facility OWNER information: <br /> Owner Name Home phone <br /> Le yro � e rt`t" r 'I ;� 3 3 q <br /> Owner DBA(if DIFFERENr from Owner Name) Business Phone <br /> Owner Address l t <br /> It'I0g0 WerefjN A ( 1hf <br /> .I <br /> City l L.odj sista zip <br /> � <br /> Mailing Address QQ <br /> if DIFFERENT from Owner Address 13 q 3 q <br /> Iva r<i ! R� <br /> Care Of or Attention <br /> (optional) <br /> II <br /> Mailing Address City State Zi <br /> o I �G�} p 5 5 <br /> Suernass bode Type of Owner Business i <br /> s� it <br /> FACILITY FILE INFORMATION <br /> FACILITY;ib # .. .. ... .. .: . .:'. ACCOUN ':�L) #..: <br /> .... <br /> Please complete the following FACILITY information: <br /> FacilitylBusinesa Nerne(This vn71 be Name on Health Permit I <br /> Facility Address(f Facility is a Mobile Food Unit or Vehicle-See below) Business Phone <br /> City ; I' Sta Zip <br /> LO] �p <br /> 13D;60::SuPti:Mb i4::D&thic r<: <br /> Lasts.TRAt T. U'AT10N.C(y[JE`. ... ;.I:........ <br /> :.::: <br /> Mailing Address(for Health Permit) <br /> I <br /> li 'I <br /> if DIFFERENT from Facility Address ,I <br /> li <br /> Care Of or Attention <br /> (optional) <br /> Mailing Address City State Zip <br /> I <br /> 51C Code> ElataodfEy 5fatus:Code General type of Businead at this Buainesa Cor(is <br /> Location Bueinoae Type <br /> Please complete the following information if Commissarrr or Operation Location (such as fair or feshval) is different from . <br /> Facility Address: <br /> Business Name I <br /> it .I <br /> Address of Operation I Phone <br /> ii <br /> City l {`State Zip <br /> i <br /> I <br /> Send all Invoices for Permit and Service FEES to: (Circle one OWNER FACILITY/BUSINESS <br /> A PROGRAM EH OO 59) or WATER SYSTEM f EH 00 59w form must be completed for each Environmental Health regulated <br /> operation at this LOCATION except UST Program (Use SWRCB forms) <br /> v Y eta Rsv�ws y � aR9 gaoun n9 os ata- it ar _ �a <br /> S <br /> i li <br />