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SAN JOAQUIN COUNTY ENVIRONMENTAL HT 0��O 1�PARTMENZ <br /> MASTERFILE RECORD INFORMA <br /> • CASE# ' <br /> OWNER ID# C/ WDD <br /> SHADED SECTIONS FOR EHD USE ONLY OWNER FILE <br /> CNI=CI:IF OWNER CURRfNrL!'ON FILE WITH EMD❑ <br /> HFfOLLORIAGBUSN=SSOWNER INFORMATION'. CO PHONE: <br /> CORlPETE �0 <br /> 7SV0 <br /> C 11 il� `A LoLast <br /> BUSINESS <br /> 11 <br /> MI Soc Sec o ax ID <br /> OWNER'S NAMr- First <br /> BUSINESS I\EANIE(If different from2��i✓{��s <br /> vs � uJ <br /> a� �c o zip <br /> $pAT <br /> 9�z <br /> OWNER'S HOME ADDRESS l <br /> CITY t'�0 I Attention arGare of <br /> OWNER'S MAILING ADDRESS (If different fromOwner's Address) <br /> $TATE QIP <br /> IVIAIL,NG ADDRESS CITY <br /> TYPE ax OWNERSHIP: COUNTY AGENCY 13 STATE AGENCY❑ FED AGENCY OTHER❑ <br /> CORPORATION C] INDIVIDUAL[I PARTNERSHIP LOCAL AGENCY❑ <br /> FAMITY FILE <br /> ACCOUNT ID <br /> �0�3'71 CO-OWNER ID#: <br /> FACILITY lD#: <br /> COfi,PLETETHEFOLLOWING BUSI NESS FACILITY INFORMA-17f3A`. YES d No ❑ <br /> Is this a NEw Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HAL No <br /> nrn��-• _- regulated Business? <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of <br /> V1Vt���� �2�C SY�2 <br /> BUSINESSIFACI��SME(This will be the 8usrxEss�NGE�Eon the HEALTH PERMIT) <br /> Z f arrsisseaY ADORES7I UO BUSINESS PHONE <br /> FACILITY to <br /> (If yFA'CILLm is a/1�fOajutf�FOOD UNITor FOOD VEH=Euse the L <br /> 1 `o W, V! `1" S I ST Saye A zip 77 7 <br /> ruse + 5FY Cir <br /> lsaf0rL1Fova Urrror Foon VEHICLE <br /> CITY(If FACruheCo.: 9 j Y V <br /> U)'01 LOCATION CODE KF-yl KEY2 <br /> T <br /> BOARD OF SUPERVISOR DISTRIC <br /> Attention orCere Of <br /> MAILING ADDRESS for Healm 1 erMff(If DIFFERENrfrom FacilrtyAdr� � /QU�� rZ �d ii,>•/!A <br /> cSTAj2,4— 7JP C� <br /> MAILING ADDRESS CITY �� I <br /> APN#: COMMENT: <br /> SIC Cooe: <br /> ACCOUALA <br /> DO ESS far fees and charges: OWNER ❑ FACILITYIBUSINE <br /> _� _ <br /> BILLING AND COMPLIANCE ACKNQWLEDGMENT: I,the undersigned Applicant,certify that 1 am the Osler,Operator,or Authorized Agent of this Business,and <br /> I acknowledge that all PERMIT FEES,PENALTIES, ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation Will be billed to me at the <br /> address identified above as the ACCOUNTAODRESS 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 JOAouIN COUNTY Ordinance Codes anchor stanaaras a�,a sz:.zc a„a,c� <br /> FEDERAL Laws and Regulations./ <br /> APPLIGANT'S NAME; � ��� SIGNATURE: :�� <br /> �` f <br /> Please Print DATE I/ Z��✓ <br /> TITLE: PHOTOCOPY REQUIRED) 3� /Z� <br /> f� <br /> Approvod ay a to t?ata I I <br /> f/ TA office Procesafng comprcted By / Deto /�3 <br /> A PROGRAM{EHD 4-02-034 Pink}or WATER SYSTEM{EHD 46-02-0031 form must be completed for each EHD regulated operation at this LOCATION <br /> except UST Program(Use SWRCl3 forms) <br /> EHD 48-02-035 Masterfile Record-Green <br /> 8119!08 <br />