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MOVED 0 ! <br /> OCT 19 2004 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> ENVIRONMENT HEALTH MASTERFILE RECORD INFORMATION FORM <br /> PERMIT/SERVICES <br /> SHADED SEC77ONSFOR EHD USE ONLY OWNER ID# ODp C) CASE# <br /> OWNER FILE <br /> COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION: CHECK IF OWNER CURRENTLY ON FILE WITH EHD <br /> BUSINESS L l✓ PHONE <br /> OWNER NAME First MI Lest <br /> BUSINES N�AM/E_(if differentflom Owner Name) Soo Secor Tavin« <br /> OWNER HOME ADDRESS — <br /> CITY j �, r r,gau/� e5. ZIP Z i t' <br /> OWNER MAILING ADDRESS (If ddferent from Owner Address) Attention or Care of <br /> . ! 3 <br /> MAILING ADDRESS CITY G STATE Z �� , <br /> TYPE OF OWNERSHIP: <br /> CORPORATION❑ INDMDUAL PARTNERSHIP El LOCALAGENCY❑ COUNTYAGENCY❑ STATE AGENCY 1-1 FED ii CY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID#: CO-OWNERID#: ACCOUNT ID#:Q <br /> COMPLETE THE FOLLOWING BUSINESS FACILITY INFORMATION: 'C <br /> IS this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO ❑ <br /> IS this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ NO ❑ <br /> BUSINESS/FACILITY NAME(This will be the BusimEss NAMEon the HEALTH PERMIT) <br /> FACILITY ADDRESS(If FAcerry Is a Moel EFOOD UNRorFOODVEHiCte use the COMM s2ARY ADDRESS,, BUSINESS PHONE <br /> Sud <br /> CITY(IfFAGUrYIs a Moer�Foot,UNmor FOOD ven¢eusa the CnMMissAOY Cm) STATE ZIP <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> MAIUNG ADDRESS for Health Permlt(If D/FFERENTfrom FaoWAddress) Attention or Care Of <br /> MAILING ADDRESS CITY 7 STATE LP <br /> SIC CODE: APN#: � �,_J/7(� COMMEM: <br /> QQQUNT AQQ9RSS for fees and charges: OWNER FACILITY/BUSINESS ❑ <br /> Rn I INr AND COMPI rANCR ACKNOWLEDGMENT: I, the undersigned Applicant, certify that I am the Owner, Operator, or Authorized Agent of this <br /> Business,and I acknowledge that all PERMIT Flies,PEIV LrTes,ENFORCEMENT Cn"UmY and/or HOURLY CHARGES associated with this operation will be <br /> billed to me at the address identified above as the ACCOUNT ADORP.SC for this site. I also certify that all information provided on this application is true <br /> and correct; and that all regulated activities will be performed in accordance with all aooHr.h" - Dunn Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations. <br /> L <br /> APPLICANT NAME: ...enATURE:. <br /> Please not <br /> TITLE: DATE 2! d ' DRNER'S LICENSE# <br /> L (PHOTOCOPY REOUIREDI <br /> Approved By Date Accounting O---Processing Completed By J12 Date <br /> A PROGRAM(EHD 46-02-034 Pink)or WATER SYSTEM{EHD 46-02-003)form must be completed for each EHD regulated operation at this except <br /> UST Program(Use SWRCB fors) <br /> EHD 48-02-035 Masterfile Record-Green <br /> 10/9/2003 <br /> oO <br />