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SAN JOAf "'IN COUNTYI�MRU3&'NMENTAL HEALTH r " RTMENT �`� [� <br /> VARECORD INFORMATION FORM *Vcy-0.VA`�0. <br /> b t � <br /> SHADED SEC17ONS FOR EHD USE ONLY EEEELZtuk:CASE# <br /> OWNER FILE <br /> COMPLETE THEFOLLOWINGBUSINESS OWNER INFORMATION; CHECKIFOWNE REN�zYo►v1rtEyvrryEHD❑ <br /> MOWNER'SMAWNG <br /> ���.—. __ _� CL-I/'r° <br /> Firsth?i Lastnt Owner hafRe) Soc <br /> 6bRESS ,� l� <br /> ZI 3�RESS (If drfferentfmm owner's Address) Attention arcane of u <br /> MAILING ADDRESS CITY STATE ZIP <br /> 'TYPE OF OWNERSHIP: <br /> " CORPORATION INDWIDUAL PARTNERSHIP❑ LOCAL AqNcY-E]jLS2=AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FI <br /> FACILITY ID# <br /> ,Co-D # �;.: a �s� �'�� .��;g Acco1INT7D# �. <br /> .�. . .. 1 <br /> COMPLETE THE FOLLOWING BUSIN ESS FACILITY INFORMATION: <br /> I5 this a NEW Business LOCATION Or VEHICLE not previously regulated by the(ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> IS this an E)MSTING Business LOCATION but a NEW TYPE of regulated Business? YES No ❑ <br /> BUSINESS/ Lrry AM is will be the BIWN Eon th H LTH PERMIt <br /> z- C� U t CCL& <br /> FACILITY ADDRESS(If,a�is a ryla9rrFFcnnU,�rer�V use the COMMISSARY�aEss) BUSINE55 PHONE 71 <br /> Scree &mber Or�'o n II tr„T^` Shc� Name t Sbreet Twe Suite# ! Is <br /> CITY(if FAaurrrs a MosiLE Fops UMT or FOOD VEHICLE use the COMMISSARY CITY 1 STATE ZIP <br /> BOARD OF SUPERVISOR DISTRICT a r i s Y LOCATION CODE a KEY[ " a5 � <br /> �. <br /> . - ., -.- .. ...,m.,. .- ss.we4:_z,,.re: .>.,— ra u .._.zm... .�'4'c8f' a.z„ ."kL.,b...w➢�.M.» C t�... a �R` <br /> MAILING ADDRESS^fat Heaftfl e1Mit(If DI�RELVTfrom FadlityAddress) Attention orCare Of <br /> MAILING DRIES $ ZEP 2/ f7 <br /> SIC CODE APN#ACCOWTAMESE <br /> for fees and charges: OWNER FACILITY/BUSINESS <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and <br /> I acknowledge that all PERMIT FEES,PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation will be billed to me at the <br /> address identified above as the ACCOUNT ADDRESS for this site. I also certify that all information provided on this application is true and correct;and that <br /> all regulated activities will be performed in accordanceith all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or <br /> FEDERAL Laws and Regulations. <br /> APPLICANT'S NAME: SIGNATURE: <br /> Please Pnnt <br /> TITLE' DATE � I +3 / DRIVER'S LICENSE# <br /> 0 J/ux // <br /> PHOTOCOPY REQUIRED) <br /> > u <br /> AP Date Acoonrtting Offtce Processing Completed By <br /> Date ' <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 <br /> LOCATION except UST Program(Use SW`RCB forms) <br /> EHD 48-02-035 <br /> 8/19/08 Mastefile Reoord-Green <br />