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i <br /> 06-03-'13 12;20 FROM-K.,� Enterprises 408-123-5678 T-787 P002/002 F-773 <br /> %7AN%1U/at,IUiN 1LULINI Y CINVIKfJNMtN1AL rlEAL7H Ut:V^tI MCNl <br /> MASTERFILE RECORD INFORMATION FORM <br /> SHAaFASECA0NSF0lilyHD(/SAON4Y [FNER 1:0# CASE# <br /> OWNER FILE <br /> COMPL€WTHEFOLLOW/NOBUSINESSOWNER AfFORMAT/ON.' CHE6K/FOWNERV11R.VeN .YONP/LEW/TNEHD❑ <br /> BUSINESS �^ PHONE: <br /> OWNER'S NAME w6O J <br /> Pint M/ Lest t� �/ <br /> BUSINESS NAME(Ifddfe ntlroml]wnerName) , / SocSecorTexlD# <br /> OWNER'S HOME ADDRESS <br /> CITY /::;/e, <br /> 1is AS 'PAT ZIP _7$_0 7 <br /> OWNER'$MAILING ADDRESS(If d//lerent lromOwner s Addreae) Attentloh orCare of <br /> MAILING AODRE3sCITY STATE zip <br /> Tmof oWNERSHIV: <br /> CORPORATION INDIVIDUAL] PARTNERSHIP[] LOCALAGENOY❑ C.OUNTYAOENCY❑ STATE AGENOY❑ FLIDAOENCY[] OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID#; S CO-OWNER ID=/: ACCOUNT ID IX: <br /> COMPLETETHBFOLLOW/NQ BUSINESS FACILITY/NF_ORMAT/ON: <br /> IS this a NEW Business LOCATloN or VEHICt E not previously regulated by the ENVIRONMENTAL HEALTH DEPARrM YES ❑ No <br /> Is1h1a an EXISTING Business LOCATION but A NEW TYPE of regulated Business? YES El NO ( <br /> BUSINESS/FACILtTY AME(Thlswil be m u9 essAtAm, lite HEALTH PERMIT) <br /> 06-rL. et.0 7 <br /> FACILITY ADDRESS(IfFAd[m9ea oedEFoaaLWi ROODVEH/Cteusethe CnMMIFLUWannaFltc) BUSINESS PHONE <br /> GA" Ww /l. so 09.8 . 9 <br /> CITY(ftPAGurV1Sa EEEoonUNrrorF000VFtfrctEusethocoMMU59 nYGmr1 STATE zip <br /> r— e r $7�1v <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> MAILING ADDRE9s forHeaMh ft/>I it(if amwaRENTfrom foo111(VA0,tessJ Attention orOare Of <br /> MAILINGADDRESSCITY STATE ZJp <br /> SiC CODA: APN$: CoMMFNT: <br /> p��l�j�fI��forfeesandcharges: OWNER ElFACILIiY/BUSINESS ❑ <br /> 131LLING AND COMPLIAMPR ACKNQWLEDGMENT: I,the undersigned Applicant,certify that 1 am the Owner,Operator,orAuthorizodAgent of this Business,and 1 <br /> acknowledge that all PERMIT FEES,Pt=NALTfe_s,ENFORCEMENT CNAnoss and/or HOURLY CHARGES associated with this operation will be billed to me at the <br /> address Identified above as 1110 ACCOUNT ADDn0Sfor this site. I also certify that all information proNded on title application Is true and correct;and that all <br /> regulated activities will be performed In accordance with all applicable SAN JoaqulN COUNTY Ordinance Codes and/or Standards and STATE and/or FEDERAL <br /> Laws and Regulations. <br /> APPLICANT'S NAME: Zce /V G SIGNATURE: <br /> F/ sepmv DRNER'SLICENSE� <br /> TITLE; � DATE�• � f pN oPYRE u1RED <br /> Approved By Data Accounting Office Processing Completed t;y Date <br /> A PROGRAM(EMD 48.02.034 Pink)or WATER SYSTEM(EHD 46-02003)form mud be completed for each EHD regulated operation of this L 30ATiON <br /> except UST Program(Use SWRCB forms) <br /> EHD 48.02.035 ( ;a Maslsrflle Record-Green <br /> 11/27/07 <br />