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SAN JOAQUIN COUNT PUBLIC HEALTH SERVICES ♦ ENVIRO -NTAL HEALTH DIVISION <br />DATE —+ MASTERFILE RECORD INFORMATION FORM (EH 0015(REvlseo 10102196) <br />SHADED SECTIONS FOREHDUSEOmY OWNER ID CASE# <br />OWNER FILE <br />COMPLETE THE FOLLOW/NG BUSINESS OWNER INFORMATION: CHECKIF OWNER CURRENTLYONFILEWITHEHD 19 <br />BUSINESS OWNER PHONE <br />NAME:_----------------------_______—_______--_. <br />First Mt Last Com) �°g ^ �o(e <br />BUSINESS NAME (If different from, Owner Name) SOC SEC /TAx ID # <br />OWNER HOME ADDRESS DRIVER'S LICENSE # <br />Ig►� F. Haactivy, <br />f ct, STATE ZIP _ <br />OWNER MAILING ADDRESS ifDIFFEREA(T from Owner Address : Attention: or Care of (option/) <br />Mailing Address City :: State ': Zip <br />TYPE OF OWNERSHIP: <br />CORPORATION ❑ INDIVIDUAL ❑ PARTNERSHIP ❑ LOCAL AGENCY ❑ COUNTY AGENCY STATE AGENCY ❑ FED AGENCY ❑ QTHER ❑ <br />FACILITY FILE <br />FACILITY ID # CROSS REF ID # AccouNT ID it <br />COMPLETE THEFOLLOW/NG BUSINESS FACILITY INFORMATION.- <br />Is <br />NFORMAT/ON. <br />Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DIVISION ? YES yg NO X <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 />Co i]crrt o� PJ bl iG ►,Ja�kS <br />T <br />FACILITY ADDRESS(/FFACILITYISA Mdal EFOOo UNITOR FOOD VEHICLE USECOMMISSARY ADDRESS) SUITE BUSINESS PHONE <br />CITY IFFACILITYISA MOBILEFooD UNITORFOOD VEHICLE USECOMMISSARY ADDRESS CITY) STATE ZIP <br />C <br />.. <br />BOARD OF SUPERVISOR DISTRICT LOCA'nou CODE KEY11:. <br />Mailing Address for Health Permit dDIFFERE/VTfrom Facility Address Attention: or Care Of (optional) <br />Mailing Address City i STATE ZIP <br />SIC CODE II APN# VI 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 />ZIP <br />A_ CCO_UNT ADDRESS 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 PERAHT FEES, PENALTIES, ENFORCEAffiVT CHARGES and/or HOURLY CHARGES <br />associated with this operation will be billed to me at the address identified above as the AccoUNTADOREss 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 FEDERAL, Laws and <br />Regulations. <br />PLEASE PRINT <br />APPLICANT NAME SIGNATURE <br />TITLE DRIVER'S LICENSE # <br />(PHOTOCOPY REQUIRED) <br />Approved By Date Accounting Office Processing Completed By Date <br />