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SAN JOAO COUNTY ENVIRONMENTAL HEALTH DEENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> SfWDED SECTIONS FOR EFID USE tlla Y <br /> Ow" tgo CASE! <br /> OWNER FILE <br /> COMAAEM7NEFOLLOWINGBUSINESSOWNER INIF'O)MITAM.' CnlEcxtFOYYlfERCr R Y°NFKEwI71"E'HO� <br /> rftfmas <br /> rj O U N A J A PHONE: 2 n <br /> NAME First Mr Last �2�1) <br /> NAME!ii dY/[rddfiamOwner Name) Soe Sec orTax ID! _ <br /> o <br /> til �p <br /> OWNER'S HOME ADDRESS -I � O4 br <br /> CITY MG STA ZIP Z,3 <br /> OWNER'S MALING ADDRESS(if al t f wowner's Address) AUmnli rr arCare of <br /> MALm ADDRESS CITY STATE ZIP <br /> TvrEOFOwr�sr: <br /> CORPORATION N�M0t1Al❑ PARTlI�SFaP❑ UnALAMOV❑ Com"ACaENCY❑ STATEAGBACY❑ FED AGtSICY❑ OTHER❑ <br /> FACILITYFILE <br /> FAGILmr ID#: to Co-OMER IO M ACCOUNT IDCQ <br /> # 8 <br /> CawPLETETHEFOLLmMe BUSINESS FACILITY AWVAA6AT/ON: <br /> Is this a NEw Business LoQATM or Ne mz notpreviously ie by the ENVIR(MENTAL HEALTH IMPARTMENT? YES ❑ No <br /> Is this an ExmTMG Bushmm LOCA m but a NEwTYPE of regulated Business? YEs M No ❑ <br /> BUSINESSIFACILtTYNAMt(This wi0 be 61AesNEiAB/WMEon the HEALTH PERAIfn i O C <br /> FACILITY ADDRESS M FAawyu a Alb"EFoa Lft7or Fano N NCLEU a the COMM MW Aoo�ssl (iV(/ BUSINESS PHONE <br /> (�q) 3 3 <br /> CITY M FAcwm a lfomEF000 uwor t o=o Ve=Eme#w Cows rQM O STAT �'� S Z <br /> BOARD o SUPBivl3oR DISTRICT LOCATDN CODE Kt C (CEv2 <br /> MALL ADams fol HaoM POrDA'[II D#TEREwk-n FacwA ss) Atli orL`are OF <br /> ZIP <br /> mmum ADDRESS CITY STATE <br /> SIC CrwE: APNS:nalwa-for fees COAarBrT <br /> and charges: OWNER ❑ FACILITYBUsINESS <br /> BILLNG AND COMPt MCE AcKNOrL0011EN1 1,Ole undersigned Applicant,cerilly that I am the Owner,Operalvr,or Autlrorized Agent of this Business,and I <br /> aldmowledge Out all PERwr Fam,PEMALTEs,ENFORCEMENT CHARGES andtor Ffamy CHARSEs associated with Otis mon will be billed to me at the <br /> address identified above as the Accooumr AWREss for this site. I also certify that all infonnsdian prodded on this application is true and correct;and that all <br /> regulated activities will be performed in accordance with all applicable SAN JoAam CouNrY Ordinance Codes and/or Standards and STATE and/or FEDERAL <br /> Laws and PiMpdations. / <br /> APPLICANT'S NAME: V DRIVER'SUCENSE�-K TA N A S R cl sdONATtI <br /> TITLE: 0 W I� �1� 71-71 DATE , Z� � Z ! <br /> Dm. ft--w"Om"Processtnp compdelsd&J Dale ! <br /> A PROGRAM(EHO 48.02.034 Pink)or WATER SYSTEM{EHO 46-02-003}form t1M be completed for gam-ENO regufabed operation at this LOCATION <br /> EHD <br /> moept <br /> UST mgrwn(UseSWRCB fomre) p m <br /> Masterfile Record-Green <br /> 11127/07 <br /> JAN 2.0 2012 <br /> ENVIRONMENT HEALTH <br /> PERMIT/SERVICES <br />