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SAN JOAQUIN COUNTY PUBLIC HEALTH SM <br /> VICES-ENVIRONMENTAL HEALTH DIVISION <br /> MASTERFILE RECORD INFORMATION FORM d{EH 00 15(Ilevised 6194)} <br /> New Facility Under Construction ' Dete <br /> HADED SECTIONS FOR LOCAL SE ONLY OWNER FILE INFORMATION <br /> ONER.Ib # . '< <br /> BASE <br /> W <br /> .# 0V1iN .oN Nt <br /> Please Complete the following facl ity OWN nformatlon: <br /> Owner Name ; I home Phone <br /> Le ro Mem ��r 1 33q - 295 1 <br /> Owner DBA I-ofD1FFEREN from Owner Narne) Business Phone <br /> Owner Address <br /> IHDgO Nor� t1 � ! lvie R� , ! � <br /> City I State Zip <br /> Meiling Address � J pp <br /> if DIFFERENT from Owner Address 13`139 f V 0 r I I/\ <br /> Care Of or Attention <br /> (optional) i <br /> i <br /> Ma ling Address City 1 O j• St p� Zip <br /> Ir G� 1 G 1 <br /> Bunneiis Code . ; t' } ; Type of Owner Business <br /> { <br /> FACILITY FILE INFORMATION <br /> FACILI'T'Y 1b ':. 1 7.�ZACCOUNT .rb # <br /> <} a.�> {}< `.{'� 4• �o><F,},,C'3 }°.v'uxCaax•-0ara <br /> Please complete the following FACILITY information: I I <br /> Facirrty/Buainess Name!This wAl be Nems on Health Perri S <br /> M�LiG�- IzDPi, � <br /> Facility Address(If Facility is a Mobile Food Unit or Vehicle-See below) Business Phone <br /> WA <br /> city1 O ` ; Ste Zip <br /> i Qmsu9 TgAC7_ BD OP'SUP6HVi80H DI57pIC7'.: ," LACATION CtltlE k}c:'� is ix:w� >,� <br /> Mailing Address(for Health Permit) <br />" if DIFFERENT from Facility Address I <br /> Care Of or Attention ' I <br /> (optional) <br /> Mailing Address City <br /> � � State Zip <br /> I <br /> 51C Code Uet Eeo�7iiy Statue'Coda General type of Business at this BuefndAi f:orts`r oK'' <br /> Location , <br /> APN�:: ar kwtr Yn'`sa >a :' 1 <i: wllnsaot'fypixawSA�i°} { � h a}. <br /> A Y <br /> Please complete the following information if CQrivnissm or OReration Locatillm such as fair or AndVal) is different from. <br /> Facility Address: ; <br /> Business Name j 1 <br /> I I <br /> Address of Operation Phone <br /> i <br /> City I State Zip <br /> i <br /> or5itv�gvl>39R�:QfAtfllci <br /> L(iC)1TInN;CoGE <br /> Send all Invoices for Permit and Service FEES to: (Circle one OWNER FACILITY/BUSINESS <br /> A PROGRAM EH 00 59 or WATER SYSTEM EH 00 59w form must be comp ate for each Environmental a regulated <br /> operation at this LOCATION except UST Program (Use SWRCB forms) <br /> V r a AagOw Vole 'joufttlna os em t e era <br /> ..� <br /> � > t <br />