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SAN JOAGUIN COUNTY PUBLIC I•EALIII SETiVICES -ENVKiONMrN]AL IIEALIH DIVISION <br /> MASTERFIL RECORD INFORMATION Fr'-)M {EH 01 15a} <br /> tiew Facility l Undor Construction Date <br /> SHADED SECT/ONS FOR LOCAL USE ONLY OWNER FILE INFORMATION <br /> OWNER �D # a <br /> .�(% CASE �T CHECK BOX:Ir OWNER ON Fps <br /> Please complete the following facility OWNER information: <br /> Home Phone <br /> Owner Name <br /> L)s � <br /> Ownar DBA(if DIFFERENT from Owner Narrml Business Phone <br /> Owner Address <br /> State <br /> City Zlp `'lS Z O Z <br /> rAniling Address <br /> if DIFFERENT from Owner Address <br /> Care Of or Attention <br /> (nptionnl) <br /> Mailing Address City State Owner Business Zip <br /> fBusiness Code Type of <br /> FACILITY FILE INFORMATION <br /> FACILITY 1D # z F Accoup ID # <br /> Please complete the following FACILITY information: <br /> raoility/Bt»ine•• Name(1Ir•W771 bo Name on 110a1th Permitl <br /> Facility Ar)drenn (N Facility is a Mobile Food Unit or Vehicle-Sea below) Business Phone <br /> City State Zip <br /> CENSUS TRACT BD OF SUPERvison DISTRICT jD6 LOCATION CODE <br /> Mailing Addre••(for H"lth Perm fJ <br /> if DIFFERENT from Facility Address <br /> Care Of or Attention <br /> (optional/ <br /> Mailing Address City Stele Zip <br /> SIC CodeUet Facility Statue Code l General type of Business at this Businaee Code <br /> Location <br /> APN A � � I Business Type <br /> Please complete the following information if Commissary or Operation Location (such as fair or festnra# is different from <br /> Facility Address: <br /> Business Name en <br /> Address of Operation Iv Joa C Phone <br /> City - , Staff Zip 20 2 <br /> CFrJ$n$ TRACT BD OF SUPER"son.DISTRICT D Q.. LOCAT1oN CODE <br /> Send all Invoices for Permit and Service FEES to: (Circle one OWNER FACILITY/BUSINESS <br /> A PROGRAM—fEH 01 15bj 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 /> I�..d byy-rwl• •v•w• y el• 000un n0. �o• wH t • wt•f t- tw •t• l <br />