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' ,AN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> SHADED SECAONS FOR EHD USE ONLYD"yyER <br /> ' �'�d"u try° 'a: '"` + +'' kF �:` as 4x,. 4 "�, r'� f�i E a1 e��� � s• wi <br /> OWNER FILE <br /> COMPLETE THE FOLLOWING BUSINESS OWNER INFORMA <br /> TION: <br /> CHECK <br /> rF OWNER Cu <br /> RREArrI YON <br /> FIL1:WITIf <br /> EHD <br /> BUSINESS avlCl �. _$ Z <br /> OWNER S NAME PHONE: <br /> Fust M/ Last 7r <br /> BUSINESS NAME(If dt1 vmt ftm Owner Name) SOC Sec arTaX ID# <br /> �.� 74IAg. <br /> OWNERS HOME ADDRESS I Yj 3 <br /> CITY SM ZIP2 y <br /> OWNER'S MAILING ADDRESS (If dlfferentfrom Owner's Address) 7Attention orCare of <br /> O0!;v -79ir-, <br /> MAILING ADDRESS CITY L O ! STATE ZIP—J <br /> �1Zy r <br /> TYPE OF OWNERSHIP: <br /> CORPORATION❑ INDIVIDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑- OTHER <br /> FACILITY FILE <br /> COMPLETE THE FOLLOWING BU SINESS FACILITYliwo NATION: <br /> Is this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES No ❑ <br /> Is this an EX15nNG Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No <br /> BUSINESS/FAcnmy NAME MIs will be the 00MVMNMreon the HEALTH PERM <br /> a 'r N a eV <br /> FACILITY ADDRESS(If FACILrrYls a MMEFCOD Uwor FWD Vauar:use the Qmtru6m Ani) BUSINESS PHONE <br /> T Suite# <br /> CITY tIfRacrcmtsaMoe UnptorFoonVEMCtFus 1 STAS I ZIP <br /> MAILING ADDRESS for Health PermK(If aft ENrfrom FadlKyAddressJ Attention or Care Of <br /> C, c <br /> MAILING ADDRESS CITY J p f I <br /> P <br /> " q R Lis 's�J �X s STA C g� I <br /> r <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. 1 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: .P SIGNATURE: of <br /> Rt <br /> Tm.E: DATE. DRIVERS LICEN E# <br /> q. ` it - I PHOTOCOPY REQUIRED) <br /> fi`"k, .¢_,r s,„�o-.ei;,;. '' fi'� „£ !;j a^ +� S=�*4 ";&f •dP 'd� "". p: s� E d• -.: Yd i t5 t <br /> r <br /> _ <br /> A PROGRAM {EHD 48-02-034 Pink) or WATER SYSTEM {EHD 46-02-003} form .M-9 be completed for each EHD regulated operation.at this <br /> LOCATION except UST Program(Use SWRCB forms) <br /> 035 <br /> 819/0808 Masterrile Record-Green <br /> 8119 <br />