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,AN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> SHADED SEcraN5 FOR EHD USE ONLY b s <br /> 11 <br /> u,. �a`k.�r..,� .-i,aa�.f�d+'x`tm<sm� <br /> OWNER FILE <br /> COMPLETE'rHE FOLLOWINGBUSINESS OWNER INFORMATION: CNECKIF OWNER CuRRENnYpN ME Wn7f EH D❑ <br /> BUSINESS <br /> I`. OWNER'S NAME dvlCt _e y PHONE: <br /> First MI Last 4 G �� j 7f�7( <br /> BUSINESS NAME(If ff&vntfinmownerName) SOC Sec orTax ID# <br /> � fl �L 'S- 06411ssI <br /> OWNER'S HOME ADDRESS' 1 3 <br /> CITY f ! STIP ZtP I <br /> OWNER'S MAILING AmEss (If dHlerentfrtAmOwner's Address) Attention orcare ofL <br /> 1�10 `79� - 7 <br /> MAILING ADDRESS CITY D _r! <br /> q S ,� zip <br /> TYPE OF OWNERSHIP: <br /> CORPORATION❑ INDIVIDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER <br /> FACILITY FILE <br /> � -< �� ��"v' i'� d3... �-.C�.:: ��E t ? �" ^�'.+�^�3$ Y�i,�+� �- € R{1FI.' �il.l�l.�it• R� �r <br /> COMPLETE THE FOLLOWING BUSINESS FACILITY INFoRMATION; <br /> Is this a NEw Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES '� No ❑ <br /> Is this an ExwnNG Business LOCATION but a NEw TYPE of regulated Business? YES ❑ No <br /> BUSINESS/FACILITY NAME(This will be the 81RsWMWN„VEon the HEALTH PERM ll <br /> 1, - e � D. , f �i/ Z �G <br /> FACILITY ADDRESS W FA=rrr{s a Ihw tE rav uATror Fow WF-a use the CrpmMrssaav Ao_o_ems) BUSINESS PHONE <br /> rDlrecbbn <br /> N+ .�..r W <br /> Suite# <br /> CITY(Ir Faaurr La a 14f (,NlT Or FOOD Vt trtC[r VS a QQMtarssAaY CITYi STA ZIP <br /> BOAItbUP a^! h {, , <br /> r. "- � TIO CODE` <br /> e <br /> MAILING ADDRESS for Health Permlt(If DmTRmrf m FddlltyAddrew) Attention orCare Of <br /> 0 0 , <br /> MAILING ADDRESS CITY STATE Zip ¢ N <br /> fi 3;!g Nib ? xb a sc $ MI♦1 £ <br /> B. a <br /> AG=IN?ADDRE,&for fees and charges: OWNER ❑ FACILITY/BUsINESS <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that 1 am the Owner,Operator,or Authorized Agent of this Business,and <br /> I acknowledge that all PERMIT FEES,PENALTIES,ENFORCEMENT CHARGES and/or HOURLY GxARGES associated with this operation will be billed to me at the <br /> address identified above as the AccouNTADnRt:ss 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 accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or <br /> FEDERAL Laws and Regulations. <br /> APPLICANT'S NAME' �� SIGNATURE: �'"f• / <br /> Please Mnt <br /> TITLE: DATE DRIVER'S LICEN E# <br /> PHOTOCOPY REQUIRED) <br /> . ,,u �. <br /> ApAy s 3 r <br /> ? � �s--=E� f z` 5 a,•' <7 _ - �1Q.�C�., in ��f �� %�� �:. r _ '`S r <br /> .,gk,, s,.�i;.:._.,, - ,. .r €. •, a ' �±%7e e9p ` ryau� na,.. � i, '" / gy <br /> fi,ES YF { ` <br /> A PROGRAM {EHD 48-02-034 Pink} or WATER SYSTEM {END 46-02-003) form must be completed for each EHD regulated operation at this <br /> LOCATIQN except UST Program(Use SWRCB forms) <br /> EHD 48-02-035 <br /> 8/19/08 Masterfile Record-Green <br />