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SAN JOAQUIN 'fNTV PURL IC HEALTH SERVICES -ENVRONMENTAL HEALTH UNISON <br /> 15a) <br /> MASTERFILE ' <br /> ,.,ECORD INFORMATION FOF � {Rte 1 <br /> Under Construction <br /> New Facility <br /> SHADED SECT/ONS FOR LOCAL USf ONLY pWNER FILE INFORMATION <br /> CHECK BOX IF OWNER ON FILE <br /> CASE # <br /> OWNER ID # <br /> Please complete the following facility OWNER information: Hems Phone <br /> Owner N.me CAPLIN - MCGIFF INC. <br /> Bueineea Phone <br /> owner DBA(if DIFFERENT from Owner rl- e) 209 477 8896 <br /> ELKHORN COUNTRY CLUB <br /> Owner Addreee <br /> 1050 ELKHORN DRIVE <br /> Stete Zip <br /> City STOCKTON CA. 95209 <br /> Meiling Add,". <br /> if DIFFERENT from Owner Address SAME AS ABOVE <br /> Cnre C'or ACMIon <br /> (optional/ <br /> Meiling Add reee Ciitty—�1 Stele Zip <br /> 8Naineer code I Type of Owner Bueinee. GOLF COURSE/ COUNTRY CLUB <br /> FACILITY FILE INFORMATION <br /> FACILITY 7D # ACCOUNT ID # <br /> Please complete the following FACILITY information: <br /> Facility/Bwinen Neme/Ttie wa b.Nemo on Heefth PerrrJf <br /> ELKHORN COUNIRY ULUU <br /> Facility Addreee (ff Facility is a Mobile Food Unit or Vehicle-See below/ Bueineee Phone <br /> 1050 ELKHORN DRIVE 209 477 8896 <br /> City State Zip <br /> STOCKTON CA. 95209 <br /> CENSUS TRACT BD OF Sur'Avisorr DISTRICT .LOCATION CODE. <br /> Mailing Add.... (for Health Permit) <br /> if DIFFERENT from Feciliiy Address SAME AS ABOVE <br /> Care Of or Attention <br /> (option./) <br /> Nleiling Addreee City Stet. Zip <br /> SIC Code Ust Feciliiy,Statue Code General type of 8ueineee w this Business Code <br /> APN # Loo F COURSE/ COUNTRY CLUB Businme Type <br /> Please complete the following information if Commissary or Operation Location /such as fair or feshvaU is different from <br /> FaclTrty Address: <br /> 8uein.ee Neme <br /> Addreee of Operation Phone <br /> City State Zip <br /> .CENSUS TMCT BD.Of.SUPERMSOR DISTRICT LOCATION CODE <br /> Send all Invoices for Permit and Service FEES to: (Circle one OWNERFACILITY/BUSINES <br /> A PROGRAM EH 01 15b or WATER SYSTEM EH 01 15c form must be completed for each Environmental Health <br /> regulated operation at this LOCATION except UST Program (Use SWRCB forms) <br /> r nu . Y Del. mMne Olnae eta rvr [ t. m <br />