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SAN.JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> SHADED SECTIONS FOR EHD USE ONLY OWNER I D# CASE# <br /> OWNER FILE <br /> COMPLETETHEFOLLOw/NG BUSINESS OWNER/NFORMAT/ON: CHEcKIF OWNER CURRENTLYONFILEWITHEHD❑ <br /> BUSINESS <br /> OWNER'S NAME <br /> • first MI La l <br /> BUSIN SS NAME(If differentfrom OwnW Name) Soc Sec orTax ID# <br /> OWNER'S H E ADDRESS <br /> CITY Sl j 4D <br /> ,3 <br /> ST zip <br /> OWNER'S MAILING ADDRESS (If different from Owner's Address) Attention orCare of LEJ <br /> LI� <br /> MAILING ADDRESS CITY ST/1j�� ZIP r aTYPE OF OWNERSHIP: `lam J U (/y� "I J <br /> CORPORATION❑ INDIVIDUAL 'PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID#: CO-OWNER ID#: ACCOUNT ID#: <br /> COMPLETE THEFOLLOwINGBUSINESS FACILITY/NFORMAT/ON.' <br /> Is this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES NO ❑ <br /> rl oo n oruuir0 <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No <br /> BUSIN IF ILITY NAME This will be the BusrN sNAME the HEALTH PERMIT) <br /> S <br /> �C V2 <br /> FACILITY ADDRES (IfFAcrLITris a`,�091LEFOOD UN/Tor FDOD VEH/cLEuSe the COMMISSARY ADDRESS) BUSINESS PHONE <br /> l 'V Suite# LZ �� <br /> CITY c/LITy(i510 MOBILEFOOD UN/T or FOOD HICLE use the COMMISSARY CITY) STA <br /> T zip <br /> s <br /> Il�'K1(JI <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> MAILING ADDRESS for Health Perm/t(If DIFFERENTfrom Facility Address) AtteWtirCare Of <br /> MAIDRES�jI�t;{-n STAT zip <br /> SIC CODE: �1 u U APN#: COMMENT: <br /> ACCOUNTADDRESS for fees and charges: OWNER FACILITY/BUSINESS ❑ <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner, 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 ACCOUNTADDRESS for this site. I also certify that all information provided on this ap IIcation' true and correct;and that <br /> all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Cod and/o S ndards d STATE and/or <br /> FEDERAL Laws and Regulations. yy <br /> APPLICANT'S NAME: Y 5Z ATUR Ely' <br /> Pl a e Print <br /> TITLE: O DA 1 I �i DRIVER'S LICENSE <br /> 2 1 <br /> 1P/t — ` �1 I PHOTOCOPY REQUIRED ✓ <br /> Approved By �)� /� Date \ ` —t Gl Accounting Office Processing Completed By Date <br /> A PROGRAM{EHD 48--02-00334 Pink)or WATER SYSTEM{EHD46-02-003)form must be completed for each EHD regulated operation at this LOCATION <br /> except UST Program(Use SWRCB forms) <br /> EHD 48-02-035 Masterfile Record-Green <br /> 8/19/08 G , <br />