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0 0 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> Shoo SEcimsFOREHD USE ONLYOWNER ID# CASE# <br /> OYIdNEIt FILE <br /> COMPLETE THE FOL LOW/NG BUSINESS OW N ER INFORMATION.' CHECK IF OWNER CuRRe�vrcY oNFiiE►mHEHO❑ <br /> BUSINESS Mark Schell PHONE: <br /> OWNER'S NAME First Mi Last 573-229-4656 <br /> BUSINESS NAME(If different from Owner Name) Soc Sec orTax ID# <br /> Diamond Pet Foods <br /> OWNER'S HOME ADDRESS 103 N Olive <br /> CITY Meta STA zIP 65058 <br /> OWNER'S MAILING ADDRESS(If different from Owner's Address) Attention orCare of <br /> MAILING ADDRESS CITY $TATE LP <br /> TYPE OF OWNERSHIP: <br /> CORPORATION❑ INDIVIDUAL® PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ <br /> to FACILITY FILE s 2- <br /> FACILITY ID#:A () ( S Co OWNER ID#: ACCOUNT ID#: <br /> COMPLETE THEFOLLOWING BUSINESS FACILITY INFORMATION.' <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 NEWTYPE of regulated Business? YES ® NO ❑ <br /> BUSINESS/FACILrrY NAME(This will be the BUS1NEssAWwon the HEALTH PERMIT) <br /> Diamond Pet Foods Processors of Ripon <br /> FACILITY ADDRESS(if FAcrtipl0Ulg4LEF000UNiTorF, 0 WHICL <br /> Euse BUSINESS PHONE <br /> 942 J (rll Ave. <br /> Suite# <br /> CITY(If FAauTYlsaMo&LEFOOD UNITOrFOOD VENIcLEuse the ComwSSARYCm) STATE ZIP <br /> Ripon CA 95366 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> MAILING ADDRESS for Health PerM t(If DIFFERENTfrom FAcilityAddress) Attention orCare Of <br /> MAILING ADDRESS CITY STATE ZIP <br /> SIC CODE: APN k. CoMMer1T: <br /> [AccOUNT —D__S for fees and charges: OWNER ❑ FACILITY/BUSINESS 11 56 <br /> 56 <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I <br /> acknowledge that all PERMIT FEES,PENALTIES,ENFORCEMENT CHARGES andlor HOURLY CHARGES associated with this operation will be billed to me at the <br /> address identified above as the ACCOUNTADDRESS for this site. I also certify that ail information provided on this application is true and correct;and that all <br /> regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/ ndards and STATE a for FEDERAL <br /> Laws and Regulations. <br /> (�1 <br /> SIGNATURE: <br /> APPLICANT'S NAME: 7 j� � t <br /> r Please rent / DRIVER'S LICENSE# <br /> TITLE: �, "q A � DATE I P PHOTOCOPY REQUIRED <br /> Approved By w Date j Accounbng Office Processing Completed By Date 1 Z� I <br /> A PROGRAM(EHD 48-02-034 Pink)or WATER SYSTEM(EHD 46-02-003)form must be completed for each EHD regulated operation at this LOCATION <br /> except UST Program(Use SWRCB forms) <br /> Masterfile Record-Green <br /> EHD 48-02-035 <br /> 11127107 <br />