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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> CASE# <br /> SHADEOSECpONSFORENDUSEONLY <br /> OWNER FILE <br /> CHECK/F OWNER CURRENTLYONF/LEWITNEHD❑ <br /> COMPLETE THEFOLLOWJNGBUSIN SS OWNER INFORMATION., PHONE: <br /> BUSINESS 1 L W S _ <br /> OWNER'S NAMEM/ Lasl <br /> Fbst Sac Sec DrTaxlDf <br /> BUSINESS NAME(If d/Karard rmmDNnorNnme) <br /> OWNER'S HOME ADDRESS AT STATE ZIP <br /> CrTV A— <br /> AtledNon orGere of <br /> OWNER'SMAILIN/G�ADDDRREESS(If d/Iferentfivm r`t�dd r` V <br /> 'O� Q . <br /> D 1E• T TE ZIP <br /> MAILING ADDRESS CITY <br /> TYPEOFOWNMHIr <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ LOCALAQENCYD COUNfVASEN STATE AGENCY❑ FEQ AGENCY❑ OTHER[] <br /> FACILITY FILE <br /> .. 'CO-OwNERIDW: - - 'AccoumTID#: -- <br /> COMPLETETHEFOLLOW/NG BUSINESS FACILITY INFORMATION, <br /> IS this a NEW Business LOCATION Or VEHICLE notpraVbualy regulated byfhe ENViRDNMEMALHEALTHDEPARTMEHn7 YES NO ❑ <br /> Is this an EXIsrING Bueinese LOCATION testa NEwTYPE f regulated Business? <br /> YES D No <br /> BUSINESSIFACILI AME IewRlbethe SaswEssAlavEON HEADPERMIT) <br /> S_ C W - '3 NA C <br /> BU81NEeSPNONE <br /> FACILITY ADDRESS(HFAerUrvlaa MDeaeFooD Ux/ro,�r,FLb+D'VExrcurueaBraC mns° .vlA fE�st �fi` - ,L16�,36gI <br /> dAi✓L �OL_�(iVL J /1 �7Gf5VU svneu <br /> STATE ZIP <br /> CITY(IfFAcwrvlsa MODNEFCDDIINROrFODD%R,,£usalhe CoMM58a CTM <br /> - - Ken - - '- KEv2 <br /> -BOARD OFSUPERVISOR DISTRICT LOCATIONCODE <br /> Aae�dlan erCare Of <br /> MAILING ADDRESS fOr Hf?BIII/PBFRt/t(IFO/FFEn NTTromI avltyAddresa) <br /> A0 L_U111T_/, STATE LPQ <br /> MAILING ADDRESS CITY <br /> J W <br /> SICCCDe <br /> rAPNtl:. - GCwAEfir: <br /> t <br /> dr' n N_�AODAESS forfees aad charges: <br /> OWNER FACILITYIBUSINESS ❑ <br /> gILUNG ANo COMPLIANCE ACKNOWLEDGMENT: I,the undersigned, pplicant,cenify that I am the Owner,Operator,orAuthor/zedAgentof this Business,and 1 <br /> URLY <br /> RGES associated with this Operation <br /> address identified tall above as the ACCO NTADORess fafthM she. Ial o certify that Oil information Apovlded n his application is true land col be lrrect a dtha all <br /> regulated activities will be perlormed in accordance with all applicable SAN JOAQUIN COUNry Ordinance Codas andlor Standards and STATE and/or FEDERAL <br /> Laws and Re Fulations. <br /> APPLIOANT'S NAME: ./J C 1 U�ICb" S SIGNATURE: <br /> /J please PrintOAS .44921 <br /> DRIVER'SUCENSE# <br /> TITLE: �/ PHOTOCOPY REQUIRED <br /> i Deb <br /> =APProved BY <br /> -Dale ',. -_, -Aaauunene Offioe Prooeaefng Completed gy .. <br /> plated for each EHD regulated operation at this LOCATIO <br /> AD ROGRAM(EHD 4&02.034 Pink)ar WATER SYSTEM(EHD 46-02 m <br /> 003)form Mggd be ea <br /> axe ptUSTProgram(Use SWRCgforms) MaIder01a Record-Green <br /> EHD 48-02.035 <br /> 11127107 <br />