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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />SHADED SECTIONS FOR EHD USE ONLY OWNER ID # 0�00,9 2 33 CASE # <br />OWNER FILE <br />COMPLETE THE FOLLOW/NGBUSINESS OWNER INFORMATION: CHECKIF OWNER CURRENTLYONF/LEw/THEHD❑ <br />BUSINESS <br />OWNER'S NAME <br />A l� <br />1� <br />VV <br />D <br />C M Y/ <br />FPHONE: <br />First <br />MI <br />Last <br />BUSINESS NAME (If different from Owner Name) <br />o n <br /> # <br />CI 'S NOMEADDRESS <br />LOCATION CODE <br />CITY V n <br />E <br />I ZIP193 0 <br />OWNER'S MAILING ADDRESS (If different from Owner's Address) <br />gwA <br />Attention or Care of <br />MAILING ADDRES ITY 3bCkbn <br />STtTA <br />ZIP 52-0 <br />TYPE OF OWNERSHIP: <br />CORPORATION INDIVIDUAL ❑ PARTNERSHIP ❑ LOCAL AGENCY ❑ COUNTY AGENCY ❑ STATE AGENCY ❑ FED AGENCY OTHER ❑ <br />���h �t �y FACILITY FILE <br />FACILITY ID #: r K (/t/ (� b CO-OWNER ID #: ACCOUNT ID #:AM <br />b �OZ <br />COMPLETE THE FOLLOWING B U S I N ES S FACILITY INFORMATION: <br />Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES NO ❑ <br />Is this an ExISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No <br />SINESSIFA ILITYAME (This will be the BUSINESS NAtfEon the HEALTH PERMIT) <br />FAcil_'II �D1aDRE(if FAOILITYisaMOBILEFOODUNITorFoOAD�VE%HHjc�L�EEus�ethe COMMISSARY ADDRESS) <br />treJ nizer Direction S, Suite# <br />BUSINESS PHONE (/ <br />a 09—W q� X <br />CITY (If FAoLITYIs a MOBILE FOOD UNITor FOOD VEHICLE use the COMMISSARY CITY) <br />STATE <br />ZIP n/ /^' <br />15 (- <br />BOARD OF SUPERVISOR DISTRICT <br />LOCATION CODE <br />KEY1 <br />KEY2 <br />MAILING ADDRESS fOrHealth Perm/t(If DIFFERENTfrom Facility Address) <br />Attention orCare Of <br />MAILING ADDRESS CITY <br />STATE <br />ZIP <br />SIC CODE: <br />APN #: <br />COMMENT: <br />ACCOUNTADDRESS for fees and charges: OWNER ❑ FACILITY/BUSINESS <br />BILLING AND COMPLIANCE ACKNOWLEDGMENT: I, the undersigned Applicant, certify that I 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 Reaulations. <br />APPLICANT'S NAME://� <br />V-, SIGNATURE: <br />Please Print <br />TITLE: �J /� [� DATE Q �j DRIVER'S LICENSE# <br />1C / A • �7 -t 1 D PHOTOCOPY REQUIRED <br />Approved By Date Accounting Office Processing Completed By N ' Date --7/3 / I <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 48-02-035 Masterfile Record -Green <br />8/19/08 <br />