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TRANSMISSION VERIFICATION REPORT <br /> TIME : 12/12/2012 10:52 <br /> NAME : SJC EHD UNIT 3 <br /> FAX : 2094683433 <br /> SER. # : BROM7F534354 <br /> :RESULT <br /> E,TIME 12112 10:51 <br /> NO./NAME 919166356666 <br /> ATION 00:00:38 <br /> PAGE(S) 01 <br /> OK <br /> E STANDARD <br /> ECM <br /> SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> SwmSjEcnwrsroREHDUsE0wLr <br /> (1 r rl •il a .rl9tlillirl uil., <br /> C0MPLE7-E7HEF0LLOW/NGBUSINESSOWNERlNFORb[4TYON;OWNER FILE <br /> BUSINESS <br /> CHECK/FOWNER cURRE`vnr0NF/LEWp7/EHD0 <br /> - <br /> OWNER'S NAME PHONE: <br /> Fuel M/ Las( <br /> BUSINESSNAME(Ifdiffimtr/'M1OWI Nsma) _. <br /> Sac Sec oFTax ID# <br /> OWNER'S HOME ADDRESS <br /> CITY <br /> STATE LP <br /> OWNER'S MAILING ADDRESS (IfdVlere/rthnnrOwneWs Addreea) <br /> Att\nticn o Cere of <br /> MAILWG ADDRESS CITY <br /> L__.. .. STATE ZIP <br /> TYPEOTOWNERSIBr: __ <br /> CORPORATION[] INDIVIDUAL(] PARTNERSHIP❑ LOCALAGENCY <br /> ❑ COUNTYAGENCY STATE AGENCY 1:1 FEp AGENCY❑ OTHCR❑ <br /> FACILITY FILE <br /> . <br /> COMPLETETHEFOLLOWLNG BUSINESSEI <br /> FACILITY//VFaaMAnoN,• <br /> Is this a NEW BOSIffess LOCATION Dr VEHICLE not Ireviousty regulated by the ENVIRONMENTAL HEALTH DEPARTMCHT7 YES ❑ No <br /> ElIs this an EXISTING Emir s LOCATION but a NEW TYPE of regulated Business? YE3 ElNo [] <br /> BUSINESS/FAcluTy NAME(This wal bathe BbAAVEsaNnmEon Na HEALTH PERMIT) <br /> FACILITY ADDRESS(tFFacurria a Masi[EFooe U,virer FooO ytNxcEuee the C�n!paes"RyAooRs ssl <br /> BUSINESS PHONE <br /> CRY(If PAOUTy15 a MOBILE FOOD UNra'row VERMLEuSa the �@ <br /> GARY Crn7 STATE ' <br /> zIP <br /> C ! <br /> . .III I �III i� b ^ � .... ��< i;. �Ih�MIRI I .'i lhN ilIT' 'k r <br /> I � ! 5 tX "'A <br /> MAILWOADDftES3for Health Permipf0/FFERENri,H FsciTdygddjggg� Atma,c�reor <br /> \Rnn...w a......_.,n M.�• <br />