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I n <br /> 'REV. 02116100 , <br /> r s ' `'i,,.eBLIC HEALTH SERVICES ° <br /> $AN.J4AQUIN COUNTY ENVfit4NMENl�:ai.HEALTH DIVISION <br /> MASTERFILE RECORD INFORMATION <br /> ~ DATE OWNER ID# �D-1q,l g CASE# <br /> OWNER FILE f <br /> COMPLETE THEFOLLOWING BUSINESS OWNER INFORMATION; CHECK IF OWNER CURRENTLY ON FILE KITH EH <br /> BUSINESS PHONE <br /> OWNER NAME 7G�(fC- (k/ V '-- 0 Z Z <br /> First MI Cas! <br /> BUSIN SS NAME (1fD1FFqRENTfty,,Bus1nsssNa e) SOC SEC I TAX 1D# <br /> OWNER HOME ADDRESS <br /> city- 71 ZI��� <br /> OWNER MAILING ADDRESS (if DIFFERENT from Owner Address) Attention:or Care of (optional) <br /> Mailing Address City State Zip <br /> TYPE OF OWNERSHIP: f <br /> CORPORATION INDIVIDII PARTNERSHIP LOCAL AGENCY COUNTY AGENCY l STATE AGENCY �/A i <br /> FE FITHER <br /> FACILITY FILE <br /> FACILITY ID# DO /2-74,, CROSS REF 1D# <br /> ACCOUNT IB# <br /> SPUBLIG H' LSN S RVlCES <br /> COMPLETE THE FOLLOWING BUSINESS FACILITY INFORMATION; � Tut 4jFA+jH DIVS10N <br /> BUSINEssIFAGLITY NAME(THIS WILL BE THE NAME ON THE HEALTH PERMIT) <br /> FACiuTY ADDRESS OR COMMISSARY ADDRESS SUITE# BUSINESS PHONE <br /> CITY OR COMMISSARY ADDRESS STATE ZIP <br /> s <br /> BOARD OF SUPERVISOR LOCATION KEY1 KEY, <br /> HEALTH PERMIT MAILING ADDRESS(if DIFFERENT from Facility Address) Attention:or Cana Of(optionaO <br /> Mailing Address City STATE zip <br /> SIC APN COMMENT <br /> ACCOUNTADDRr:ss for fees and charges OWNER FACILITY/BUSINESS <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I, the undersigned Applicant, certify that I am the Owner, Operator, or <br /> Authorized Agent of this Business, and I acknowledge that all PERMIT FEES',PENALTIES,ENFORCEMENT CHARGES and/or HOURLY <br /> CHARGES associated with this operation will be billed to me at the address identified above as the ACCOUNTADDRESS for this site. I " <br /> also certify that all information provided on this application is true and correct; and that all regulated activities will be performed <br /> in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or FEDERAL Laws <br /> and Regulations. <br /> APPLICANT NAME(Please Print) SIGNATU <br /> TITLE DRR'S LICENSE <br /> (PHOIVOPY REQUIRED <br /> Approve By Date Z b Accounting Office Processing Completed Sy Date g O <br /> w°` <br />