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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILERECORD <br /> - INFORMATION FORM <br /> SHADED SECTIONS FOR EHD USE ONLY OWNER IDR Ofl/Li(/LcJ CASEM_ <br /> OWNER FILE <br /> COMPLETE THEFOLLOWNG BUSINESS OWNER INFORMATION.' CHECKIF OWNER CURRENTLyomnLEwn7iEHD❑ <br /> BUSINESSI/r I ft•(�� t A. m n J�� PHONE: <br /> OWNER'S NAME f �. es pwq)5511 /-7 <br /> BUSINESS NAME(RrBRermdssmOWner Nems) V � ti U LJ a Soo Seo orTax ID R <br /> p� F'YIJ�PA'1 'J� Cdo�1�J' <br /> OWNER'S HOME ADDRESS: 5"/07 Di1rh4Y✓1 fer(f P-1. <br /> CITY 704 <br /> STATE (A zip 853194 <br /> OWNER'S MAILING ADDRESS (If dhTemnt from Owner's Address) Attention or Care of <br /> MAILING ADDRESS CITY STATE ZIP <br /> TYPEof OVMErt . <br /> CORPORATION❑ INDIVIDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACnm ID M Co-OWNER ID#: AccouNT ID#: <br /> COMPLETE TIIEFGLLow/NGBUSINEBB FACILITY INFORMATION.' <br /> Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? I YESEf No ❑ <br /> Is this an Ex=NG Business LOCATION but a NEw TYPE of regulated Business? YES ❑ No <br /> BUSINESS/FACILITY NAME(This will be the B�MN1Eon the HEALTH PERMIT) APN: <br /> rvjc0 ,r Gooklrr <br /> FACILITY ADDRESS(if FADerrris a moea 000 Uaror FDoo l/EroaEuse C9FMtssMr ADDRESS) BUSINESSPHDNE <br /> 5q37 D✓►k� Fty Pf (zD q)5-17—/929' <br /> slhw gntler I D)seb'ae I Seee AH Slreef T de N <br /> CITY(If FAfSRra s MOMSEFOOD UNTror F000 YE) /Ise the COMWSSARY CTM TvO(j STATE ZIP r�l'631630,51'BOARD OFSUPEIMSDR DISTRICT LOCATIOHOODE KEY1 KEY2 <br /> MAILING ADDRESS for Health PerMlt(If DIFFERENrfrom FwJltyAddess) ABenem arcane Of <br /> MAILING ADDRESS CITY I STATE LP <br /> EMAILADDRESSFOR FOR INVOICE �,I,whkr iAendcookierLpgMe�l• '"YOKE 'iN nna N1mNnzaC1i NRNd-"o <br /> INVOICES f9AAIL'I M EMAIL2 J <br /> EMAIL ADDRESS FOR PERMITkrl f7 GCI,f'coo�'i�P�fll�°�9fh%iI GaM PERMIT Ili61✓I YI GIGIIY+IG1►17-o1��r�loN/�• Coln <br /> OPERATING PERMITS EMAILf EMAIL2 v <br /> ACCOUNTA0j2&F.8forfees and charges: OWNER FACILITYIBUSINESS ❑ <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the Undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and <br /> I acknowledge that all PERM?FEES,PENALPES,ENFORCEMENT CHARGES and/or HouRLY CHARGES associated with this operation will be billed to me at the <br /> address identified above as the AccouHTAODREss for this site. I also certify that all Information provided on tots application is true and correct;and that <br /> all regulated activities will be performed In accordance with all applicable SAN JOAQUIN COUNTY Ordinance es and/or Standards and STATE and/or <br /> FEDERAL LAMS and Regulations. Jp In �} <br /> APPLICANT'S NAME: K Y i d i-e h r 'I m i ll m SIGNATURE: CM <br /> C�.t✓CM.' <br /> Please Pdnf ,,r i DRIVER'S LICENSE R <br /> TITLE: DATE U I/0_I / ]r2 �CJ r P <br /> PHOTOCOPY REQUIRED) <br /> Apprond By Deb AapelUM Office ProneWng Cenroleted aY Dab 2� <br /> A PROGRAM(EHD 48.02-034 Pink)or WATER SYSTEM{EHD 48-02-003)form must be completed for each EHD regulated Operation at this LOCATION <br /> except UST Program(Use SWRCB forme) <br /> EHD 48-02-035 Masterfile Record-Green <br /> 911 A/2020 <br />