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REV. 02/16/00 <br /> SAN JOAp UIN COUNTY � ACBLIC HFJILTH SERVICES r ENVIRONMENTAL HEALTH DIVISION <br /> MASTERFILE RECORD INFORMATION <br /> DATE OWNER IDN CASE# <br /> OWNER FILE <br /> COMPLETE THEFOLLOW)NGBUSINESS OWNER INFORMATION: CNECKIF OWNER CURRENTLY ON FIE KITH EHD ❑ <br /> BUSINESS <br /> OWNER NAME PHONE <br /> FW u ar <br /> BUSINESS NAME (If DIFFERENT Irom Business Name) Soc SEc/Tax ID N <br /> OWNER HOME ADDRESS <br /> city <br /> STATE LP <br /> OWNER MAILING ADDRESS (If DIFFERENT from Owner Addrass) Attention:or Care of (optional) <br /> Mailing Address City State Zip <br /> TYPE OF OWNERSHIP: <br /> ------------- <br /> CO PORATION INOMDUAL PARTNERSHIP LOCAL AGENCY FI I COUNTY AGENCY F1 STATE AGENCY FEE)AGENCY OMEq <br /> ri <br /> FACILITY FILE <br /> FACILITY ID# CROSS REF IDN ACCOUNT ID# <br /> COMPLETETHEFOLLOWING BUSINESS FACILITY INFORMATION: <br /> BUSINESS/FACi-nY NAME(THIS WILL DE THE NAME ON THE HEALTH PERMIT) <br /> FACILITY ADDRESS OR COMMISSARY ADDRESS SUITE# BUSINESS PHONE <br /> CITY OR COMMISSARY ADDRESS STATE ZIP <br /> BOARD OF SUPERVISOR I I LOCATION KEY1 KEY2 <br /> HEALTH PERMIT MAILING ADDRESS(If DIFFERENT from Facility Address) Attention:or Cara Of(Opeunag <br /> Mailing Address Clty <br /> STATE LP <br /> SIC APN <br /> COMMEM <br /> ACCouNYAoDREss for fees and charges OWNER FACILITY/BUSINESS <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I, the undersigned Applicant, certify that I alll file Owner, Operator, or <br /> Authorized Agent of this Business, and I acknowledge (flat all PERMIT rELS,PENALTIES, E•NFORCEMLNT CIIARGEs and/or HOURLY <br /> CIIARGES associated with this operation will be billed to me at the address identified above as the ACCoUNTADDRESS for this site. I <br /> also certify that all infortuation provided ou this application is true and correc(; and that all regulated activities will be performed <br /> in accordance will] all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or FEDERAL Laws <br /> and Regulations. <br /> APPLICANT NAME(Please Print) SIGNATURE <br /> TITLE D <br /> (VNOTOCOPY REQUIRED <br /> Approved By Date Accounting Office Processing Completed By Date <br />