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SAN.JON COUNTY ENVIRONMENTAL HEALTH WARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> SHADED SECTIONS FOR EHD USE ONLY OWNER ID# CASE# <br /> OWNER FILE <br /> COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION. CHEcKxF OWNER CURREA?LYONimLE wxmEHDN/ <br /> BUSINESS ou ' ?-,PTTP0JAS f E: <br /> OWNER'S NAME Fast Mt Last <br /> BUSINESS NAME(If&TaTntfivm Owner Name) Soc Sec arTax ID# <br /> G Imo` '�'` �C - 2f-> -�;g. tLI <br /> OWNER'S HOME ADDRESS '] <br /> CITY C4 V ` ST Z*' <br /> el <br /> OWNER'S MAnm ADDRESS(If Mblentf m Owners Address) Attention orCare of <br /> .5v S . fif o 9C4 n- S GC71 Sa v)e- -7 <br /> MAAILING ADDRESS CITY + E�y ST Ztp �✓Zj <br /> TYPE OF OWNERSHIP: (- <br /> CORPORATION INDMDuAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FAGIUTY 1D#: �) CO-OWNER ID#: Accouter ID#: <br /> COMPLETE THE FOLLOWINGBUSINESS FACILITY INFORMATION <br /> Is this a NEW Business t.00A m or VEHICLE not previously regulated by the ENVIRONMEwAL HEALTH DEPARTMENT? YES ❑ No <br /> Is this an ExIMNG Business LOCATION but a NEW TYPE of regulated Business? YES No ❑ <br /> BUSINESS/FACILIrr NAME(This will be the 5uw&ssXwEon the HEALTH mu" <br /> n n _? C' <br /> FACILTIY ADDRESS(If a m'is a matrr rcw ot t&mr Fan wmaEuse the Cosa�xir&0o k) (% iAUSDIESS PHONE <br /> CITY(If FAourre a AkejLEFboD I.MwTor Fbw Va#cteuse Ow CorrAssARY Ctrv) STATE ZIP <br /> t,oD <br /> &A <br /> BOARD OF SUPERVISOR DISTRIcr LOCATION CODE KEYi KEY2 <br /> Mmum ADDRESS for Heaft P&mJtaf DIFfERENTfrom FaahtyAddre ) Attention orCare Of <br /> MAILING ADDRESS CITY STATE LIP <br /> SIC OODE: COMMENT: <br /> AQQ2M TADRJUM for fees and charges: OWNER ❑ FACMYBUSINESS <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that 1 am the Owner,Operator,or Authorized Agent of this Business,and <br /> 1 acknowledge that all PERierr FEES,PENAL77Es,ENFORCEmffNT CHARGES and/or HOURLY CHARGES associated with this operation will be billed to me at the <br /> address identified above as the AccoumTADDREss for this site. 1 also cert fy that all information provided on this application is true and correct;and that <br /> all regulated activities will be performed in accordance with all applicable SAN JOAQm COUNTY Ordinance Codes andfor Standards and STATE and/or <br /> FEDERAL Laws and Regulations. g <br /> APPLICANT'S NAmo �Q-') 1Z 1 1—A N AS AC,i — slclW►,vRE: - <br /> f 2 <br /> TInE: }`` -17 DATE �y ltw n <br /> Approved By Date Accounting Clftlte ung Completed By � Da <br /> A PROGRAM {EHD 48-02-034 Pink} or WATER SYsYEM {EHD 46-02-003} foam must be completed for each EHD regulated operation at: this <br /> LOCATION except UST Program(Use SWRCB forms) <br /> EHD a8-02-035 <br /> 8/19/08 Masterfile Record Green <br />