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SAN.JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> SHADED S£CnONS FOR EHD USE ONL Y OWNER ID# CASE# <br /> OWNER FILE <br /> COMPLETE THE FOLLOWING BU SI N ESS OWNER INFORMA now CHECK IF OWNER CURREffn Y ON FILE WrrHEHD❑ <br /> BUSINESS Dollar Tree Stores, Inc. PHONE: 757-321-5000 <br /> OWNER'S NAME <br /> Fist Af! Las! <br /> BUSINESS NAME(If different fvn,Owner Name) Soc See arTax ID# <br /> Dollar Tree#07648 54-1387365 <br /> OWNER'S HOME ADDRESS 500 Volvo Pkwy <br /> CrrY Chesapeake ST�TE Zip 23320-1604 <br /> OWNER'S MAILING ADDRESS (If different from Owneen Address) Attention orCare of <br /> 500 Volvo Pkwy, Licensing Licensing <br /> MAILING ADDRESS CITY Chesapeake SWE I TJP 23320-1604 <br /> TYPE OP OwN018WP: <br /> CORPORATION[3 INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID#: CO-OWNER ID#: AcCOUNT ID#: <br /> COAfPLETLc THEFOLLOWING BUSINESS FACILITY INFORMATION.' <br /> IS this a NEW Business LOCATION or VEHICLE not prevkKaly regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ® NO ❑ <br /> Is this an ExisrING Business LOCATION but a NEW TYPE of regulated Business? YES ® No ❑ <br /> BUSINESS/FACIt.1TY NAME(This will be the B4s&z5vAUAiwon the HEALTH PERMIT) <br /> Dollar Tree#07648 <br /> FACILJTY ADDRESS(tf FAcrurria a MOs/LEFODa Uwiror Faoa WH cL£use the Comm*. ARY ADDeEss) BUSINESS PHONE <br /> 318'4Maing St Sanaa 757-321-5000 <br /> CITY iH FAuurris a Mos;LEFOOD Urn or Foos VeicLE use the COuMi9gwY Crrrl STATE Zip <br /> Ripon CA 95206-3341 <br /> BOARD OF SUPERVL9oR DISTRICT LOCATION CODE 7777 <br /> 1 KEY2 <br /> MAILINGADOREss krHeslth Perm/t(IfDIFFERENTfrom FacffityAddress) Attention orCare Of <br /> 500 Volvo Pkwy Licensing <br /> MAILING AoDRESS CITY STATE ZIP <br /> Chesapeake VA 23320-1604 <br /> SIC CODE: APN f/: Cataexr. <br /> ACOWfITADDRESS 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 Agenf of this Business,and <br /> acknowledge that all PERM7r FEES, PENALnEs,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation will be billed to me at the <br /> address Identified above as the AccouNrADORESs for this site. 1 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. <br /> Deborah E.Miller <br /> APPLICANT'S NAME: SIGNATURE: UJ,*,6kR. L. <br /> �ic�Ic'r(cyP�YOt$tj�i�'P[ill.�tdt.2 <br /> TITLE: DATE j�. _' DRIVER'S LICENSE# <br /> J PHOTOCOPY REQUIRED <br /> Approved By Data Aceamting Office Procaaaing Completed By Dab <br /> A PROGRAM(EHD 48-02-034 Pink)or WATER SYSTEM(EHD 4&02-003)form must be completed for each EHD regulated Operation at this LOCATION <br /> except UST Program(Use SWRC13 forms) <br /> END 48-02-035 Masterfile Record-Green <br /> 11127107 <br />