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SAN JOAQUIN COUN' • PUBLIC HEALTH SERVICES • ENVIR( ENTAL HEALTH DIVISION <br />FORM (EH 0015(REVISED 10/02/96) <br />DATE 12w Q-:� 1 MASTERFILE RECORD INFORMATION <br />SHADED SECTIONS FOREHDUSEONLY 11 OWNER ID91 11 CASE# <br />OWNER FILE <br />COMPLETE THE FOLLOW/NG BUSINESS OWNER INFORMATION.- CHECKIF OWNER CURRENTI YONFILEwITHEHO a <br />.........................................................................................:..................:..................................................................... ... ................................................................................................. <br />BUSINESS OWNER PHONE <br />NAME---------------------------------------- Czon) 4(0�K� <br />...................................................................First...............!.................................................Last.......................... <br />BUSINESS NAME (If different from Owner Name) Soc SEC / TAx ID # <br />i OWNER HOME ADDRESS I i DRIVER'S LICENSE # <br />City f �/ STATE ZIP 95Z -os - <br />OWNER <br />5Z -os - <br />OWNER MAILING ADDRESS ifD1FFERENTfrom OwnerAddress i /Attention: oor'Care�off ,(optional) <br />Mailing Address City State Zip <br />TYPE OF OWNERSHIP: <br />CORPORATION ❑ INDIVIDUAL ❑ PARTNERSHIP ❑ LOCAL AGENCY ❑ COUNTY AGENCY STATE AGENCY ❑ FED AGENCY ❑ OTHER ❑ <br />FACILITY FILE <br />FACILITY ID # CROSS REF 1D # ACCOUNT.ID <br />COMPLETETHEFOLLOW/NG BUSINESS FACILITY INFORMATION. <br />Is this a NEW Business LOCATION or VEHICLE not Previously regulated by the ENVIRONMENTAL HEALTH DIVISION ? YES ❑ NO A <br />Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business ? YES No ❑ <br />BUSINESs/FACILITY NAME ( THIS WILL BE THE NAME ON HEALTH PERMIT) _ <br />FACILITY ADDRESS(/FFAGUTYISA Mda&EF000 UmTOR FOOD VEHICLE USECOMMISSARY ADDRESS) SUITE# BUSINESS PHONE <br />S-3coc <br />CITY IF FAC/L/TYISAMoa&E FOOD UNIT OR FOOD VEHICLE USE COMMISSARY ADDRESS CITY) STATE ZIP <br />No <br />cam. (� 9S 33 <br />BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEYI - - - KEr2 <br />Mailing Address for Health Permit WD1FFEREAITfrom Facility Address Attention: or Care Of (optional) <br />l�tln ccJ.,��fa-... <br />Mailing Address City <br />ZIP <br />SIC CODE .:: APN# .:: ii -COMMENT.*. <br />THIRD PARTY BILLING INFORMATION: Complete if Billing Party is different from Business Owner Identified above. <br />---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br />BUSINESS NAME Attention: or Care Of (optional) <br />Mailing Address PHONE <br />CITY STATE i ZIP <br />ACCQUNTADDRESS for fees and charges OWNER ❑ FACILITY/BUSINESS ❑ THIRD PARTY BILLING ❑ <br />BILLING AND COMPLIANCE ACKNOWLEDGMENT: I, the undersigned Applicant, certify that I am the Owner, Operator, or Authorized <br />Agent of this Business, and I acknowledge that all PERVIT FEES, PENALTIES, ENFORCEbIE.NT CHARGES and/or HOLRLY CHARGES <br />associated with this operation will be billed to me at the address identified above as the ACCouNTADDRESS for this site. I also certify <br />that all information provided on this application is true and correct; and that all regulated activities will be performed in <br />accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or FEDEu:u Laws and <br />Regulations. <br />PLEASE PRINT <br />APPLICANT NAME SIGNATURE <br />TITLE DRIVER'S LICENSE # <br />(PHOTOCOPY REQUIRED) <br />Approved Ely Data Accounting Office Processing Completed By Date l <br />