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SAN vJOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> SHADED SECAONSFOR EHO USE ONL Y OWNERID# <br /> DARE# <br /> OWNER FILE <br /> COMPLETE THEFOLLOWWGBUSIN SS OWNER INFORMATION.' <br /> CHECK/F OWMER CURRENrLYON F/LEWITNEHD❑ <br /> "HOMEADDRESS <br /> J ' 1� rl` 1 , 1 <br /> V w � PHONE' <br /> I <br /> FBbt All 1 <br /> NAME(Iftfro Owne Mame) <br /> Brvn Sec mTav In a <br /> ESS viA <br /> AI <br /> - STATE ZIP <br /> OWNER'S MAILING ADDRESS(Ifd/Narent/m e.Address) <br /> 1010 E. k+6(\ e AtleMicn orCereM <br /> MAILING ADDRESS CITY <br /> T TE ZIP <br /> IYPEOFOWNFa9WP. <br /> CORPORATION❑ INDIVIDDAL❑ PARTNERSHIP❑ LOCALAGENCY❑ COUNTY ADEN STATEAGENGY❑ FEOAGENCY❑ t7mER❑ <br /> FACILITY FILE <br /> FACILITY ID#:. - CO-OWNERID#. <br /> AccouNT ID#: <br /> COMPLETE7NEFOLLOWING BUSINESS FACILITY INFORMATION.' <br /> Is this a NEW Business LOCATION or VEHICLE notpreviouslyregulated by tha ENVIRONMENTAL HEALTH DEPARTMENT? YES NO ❑ <br /> Is this an OUSTING BLLalness LOCATION but a NEINTYPE Ofreguleted Business? YES ❑ No <br /> BUSMESSIFSI AME Iewlll be Rre auaa sAweon HEAL7HPERNIT) <br /> `�— -E- <br /> FACILfTYADDRESS(HFADanvleeMlus aFbso UNNMFaw VNucwe lheooummAaYAo gl <br /> H(yL�- I(; 1„ BUSINE93PHONE <br /> ti "" ,` �J, A Cx l (s�u �llctfic A _0-35q I <br /> smea <br /> CITY(If FACIUrY IS a MOBILE FOOD LIW or FORD Vtlucmuse the COmwssw CUM STATE LP pp^� <br /> ^V <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> MAILING ADDREs3{Of Hea�/PB/r7r%t(If 0/FFERENT(rom ac!/ltyAtltlrcrsJ ALtentim o Care Or <br /> (�10 z.�1}rin vf, <br /> MAILING ADDRESS CITY TE ZIp� <br /> c, M1J T <br /> SIC CODs APN a: QOLB.IENT. - <br /> BCC <br /> TO ESSfor fees and charges: OWNERFACIOTY/BUSINESS ❑ <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that l am the Owner,operator,or Authorized Agentofthls Business,and <br /> acknowledge that all PERMH FEES,PENALTIES,ENFORCEMENT CHARGES andlor HOURLY CHARGES OSSOClated with this Operation will be billed to me at the <br /> address Identified above as the ACCOUNTADDAess for this site. I also certify that all Information provided on this application Is true and correct;and that all <br /> regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or FEDERAL <br /> Laws and Regulations. 1 �p 61 <br /> APPLICANT'S NAME: �JC 7 UJIG yV O`F-S SIGNATURE: �r <br /> F/Rare&W <br /> TITLE: DATE DRIVER'S LICENSE# <br /> PHOTOCOPYREpU1flED <br /> 'APProved BY Data Acosunung 01 ProoeealnD Oompleted By Date <br /> -02.003)form must be completed for each EHD regulated operation at this LOCATION <br /> A PROGRAM{EHD 4&02-034 pink}or WATER SYSTEM{EHD 46 <br /> except UST Program(Use SWRCB forms) <br /> EHD 4M2.035 <br /> 11/27107 Masterfile Record-Green <br />