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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> StWED SECWNS FOR END USE ONLY <br /> COMPLETE rNEFOLLOWINGBUSINESS OWNER MwRmoirroNWNER FILE <br /> CHFcxrF OWNER CuxREAtrLrolYFlr.EwrnYEHD❑ <br /> BUSINESS —�' <br /> OWNER'S NAME l O D' �{ Za PHONE. //�� <br /> First M1 Last (� �I r 856 <br /> BUSINESS NAME(If drflermtfiVM Owner Name) <br /> z <br /> Soc SeC arTax ID# <br /> E( t t)v + Gi,-�01F- <br /> OWNER'S HOME ADDRESS )'p' EJ 2 3 t y� FGG C _ <br /> CITY 5 U <br /> S 2 N k"t }etj CA STATE QIP /� G•3 <br /> OWNERS MAILING ADDRESS(If d1 Le,Mt&CM Owner's Address) Attention orCare of �C <br /> d • 60)c X23 <br /> MaLING ADDRESS CITY �le, STATE zip Y 4 <br /> oo <br /> i�-t z <br /> TYPE OF OWNERSHIP: <br /> CORPORATION❑ INDIVIDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER <br /> FACILITY FILE e r l tL 2+GC Lu ID <br /> FACILny 1 D#; <br /> o z�- <br /> ACCOUNT; DO <br /> COMPLETE rHEFOLLOWINGSUSI NESS FACILITY rwoRMol7zoN: <br /> Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES � N� <br /> Is this an EXISTING Business LOCATION but a NEw TYPE of regulated Business? YES ❑ No <br /> BuSINEss/FACILIIV NAME(This will be the SLWAMSNAWon the HEALTH PERMIT) <br /> FACILITY ADDRESS(If FAcnrrris a Mc8&EAxv Urorror Focv P25Faaeuse the Cowl AonREss) <br /> . �� Ei(, r s BUSINESS PHONE <br /> c� TrLc- cou r! <br /> t <br /> T Suite <br /> CITY(M FACrurr Is a MOWLE Food UnrT or Foos VEMCLE use the COnx�nss_nnv Cml J D b STATE zip <br /> k-e �o e_ <br /> x ; <br /> 6. <br /> //y.� <br /> MAILING ADDRESS for Heaft Perm/ If DIF,-meNTrmrn F"ItyAddre55) Attention. <br /> nrCare Of <br /> ey AMS <br /> MAILING ADDRESS CITY STATE ZIP <br /> SIC Coos: <br /> 0%for fees and charges: OWNER ❑ FACILITYIBUSINESS <br /> BILLING AND COMPLL4NCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and <br /> I acknowledge that all PERMIT FEES,PEuaLnES,ENFORCEMENT CHARGES and/or HouRLY CHARGES associated with this operation will be billed to me at the <br /> address identified above as the AccouNTAnnREss 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 ccordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes andlor Standards and STATE and/or <br /> FEDERAL Laws and Regulations. p f t Z1A 2_r r /4 <br /> APPLICANT'S NAME: Lf SIGNATURE: ? <br /> Please Pri <br /> TITLE: �� O i� DATE L _ � ' DRIVER'S LICENSE#PHCPI--L_ I� (p <br /> OTOCOPY RE UIRED C040 <br /> jj,�By patie <br /> Acdcuntlilg Office Processing CompletedVy <br /> Gl 3 <br /> A PROGRAM (END 48-02-034 Pink). or WATER SYSTEM (EHD 46-02-003) form must be completed for eer END regulated operation at this <br /> L TI N except UST Program(Use SWRCB farms) <br /> EHD 48-02-035 <br /> 8/19/08 Masterrile Record-Green <br />