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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />SHADED SECTIONS FOR EHD USE ONLY OWNERID# W402.E90D CASE# <br />OWNER FILE <br />COMPLETE THEFOLLOww BUSINESS OWNER lwowmloilCHECK IF OWNER CuRRENTL y oN FaE wirH EHD❑ <br />BUSINESSPHONE: <br />t <br />YES <br />No ❑ <br />i rre- Z <br />C 6) I- n <br />OWNER'S NAME <br />I ii:373oo <br />910 <br />Irs <br />Street Numtrer I Oirecttan I Street Name <br />I Street type Suite <br />BUSINESS NAME (If different fromowner Name)3eC <br />CITY (if FAcimis a MOSILEFOOD UNITor F000 VEHrcte use the Coaesssmy Cm Cm) <br />5 X19 W D_r ti(,> r 1( n L -o b,,-7 9 -Tr <br />rTax ID # <br />STATE <br />- <br />ZIP <br />% Z� <br />BOARD OF SUPERVISOR DISTRICT <br />e <br />KEY2 <br />OWNER'S HOME ADDRESS: 3 C> dLAJ <br />r O yJ IN G <br />Attention orCare Of <br />CITY C <br />STA <br />ZIP <br />EMAILADDRE88FOR <br />INVOICES <br />ZIP <br />9'-5 L. 0S <br />ADDRESS (If different from Ownera Address) <br />Attention crCare of <br />EMAIL ADDRESS FOR <br />OPERATING PERMITS <br />PERMIT t <br />nERMAILING <br />a ✓V , W I S e t) <br />EM I p <br />DRESS CITY O C <br />oil <br />STATE <br />C <br />ZIP <br />q <br />Szo <br />TYPE OF OWNERSHIP: <br />CORPORATION ❑ INDIVIDUAL ❑ PARTNERSHIP ❑ LOCAL AGENCY ❑ COUNTY AGENCY ❑ STATE AGENCY ❑ FED AGENCY ❑ OTHER ❑ <br />FACILITY FILE <br />•,FACILM ID#: 72 CO.OWNERID#: ACCGuNTID#'r <br />COMPLETE THEFOLLOw/NO BUSINESS FACILITY /NFORMAT/ow <br />Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL H TH DEPARTMENT? YES ❑ NO <br />Is this an EXISTING Business LOCATION but a New TYPE of regulated Business? <br />YES <br />No ❑ <br />BUSINESSIFACIUTV NAME (This will be the aUSWMNAMon the HEALTH PERMIT) <br />APNI <br />FACILITY ADDRESS (N FACILRYIS a MOBILEFOoD UNTor FOOD Wn=Fuse the COMMISSARY MORES SI <br />BUSINESS PHONE: <br />Street Numtrer I Oirecttan I Street Name <br />I Street type Suite <br />CITY (if FAcimis a MOSILEFOOD UNITor F000 VEHrcte use the Coaesssmy Cm Cm) <br />5 X19 W D_r ti(,> r 1( n L -o b,,-7 9 -Tr <br />VI <br />STATE <br />- <br />ZIP <br />% Z� <br />BOARD OF SUPERVISOR DISTRICT <br />LOCATION CODE KEY1 <br />KEY2 <br />- <br />MAILING ADDRESS for Health PerMit(f O/FFERENTfrom FaciiityAddress) <br />Attention orCare Of <br />MAILING ADDRESS CITYt% / (j/s- O <br />1�1�l �Y <br />STATE <br />ZIP <br />EMAILADDRE88FOR <br />INVOICES <br />INVOICE <br />EMAILI I I <br />l <br />0• D <br />INVOICE <br />EMAIL2 <br />m <br />EMAIL ADDRESS FOR <br />OPERATING PERMITS <br />PERMIT t <br />PERMIT <br />EMAIL2 <br />EM I p <br />ACCOUNTADDRESSfOrfees and charges: OWNER <br />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 CHARGES associated with this Operation will be billed to me at the <br />address identified above as the ACCOUNTADDRESS 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 />A PROGRAM (EHD 48-02-034 Pink) or WATER SYSTEM (EHD 46-02-003) form must be completed for each EHD regulated Operation at this LOCATION <br />except UST Program (Use SWRCB forms) <br />EHD 43-02-035 Masterfile Record -Green <br />9M4I2020 <br />