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REV. 02/16/00 / <br /> SAN JOAQUIN COUNTY A BLIc HEALTH SERVICES L ENVIRONMENTAL HEALTH DIVISION <br /> MASTERFILE RECORD INFORMATION <br /> DATE OWNER ID# CASE# <br /> OWNER FILE TQ O-5 r sv I <br /> COMPLETE THE FOLLOINlNGBUSINESS OWNER/NFORMATION: CHECKIF OWNER CURRENTLY ON FILE H7THEHD <br /> BUSINESS <br /> PHONE <br /> Fj- <br /> OWNER NAME <br /> F4 MI Lesl <br /> BUSINESS NAME (If DIFFERENT from Business Name) Soc SEc/Tax ID# <br /> OWNER HOME ADDRESS <br /> City <br /> STATE LP <br /> OWNER MAILING ADDRESS (if DIFFERENT from OwnerAddress) Attention:or Care of (opdonag <br /> Mailing Address City State Zip <br /> TYPE OF OWNERSHIP: <br /> CORPORATION ri INDMDUA PARTNERSHIPFJI I LOCALAGENCY M1 COUNTYAGENCYF11 STATEAGENCY FED AGENCY OTHER <br /> FACILITY FILE <br /> FACILITY ID lq7 , - CROSS REF ID# ACCOUNT ID# <br /> COMPLETE THEFOLLOW/NG BUSINESS FACILITYINFORMAT/ON: <br /> BUSINESS/FACILRY NAME(THIS WILL BE THE NAME ON THE HEALTH PERMIT) <br /> FACILITY ADDRESS OR COMMISSARY ADDRESS SUITE BUSINESS PHONE <br /> CITY OR COMMISSARY ADDRESS - STATE LP <br /> BOARD OF SUPERVISOR I I LOCATION KEY1 Ker2 <br /> HEALTH PERMIT MAILING ADDRESS(/f DIFFERENT from Facility Address) Attention:or Care Of(op#onall <br /> Mailing Address City STATE ZIP <br /> SIC APN COMMENT <br /> ACCOUNTADOREss for fees and charges OWNER FACILITY/BUSINESS <br /> BII,I,ING AND COMPLIANCE ACKNOWLEDGMENT: I, the undersigned Applicant, certify (Ila( I am file Owner, Operator, or <br /> Authorized Agent of(his Business, and I acknowledge that all PERMIT PEES,P6NALTIL•S,ENFORCEAfENT CIIARGLS and/or.HOURLY <br /> C/uRGCS associated with this operation will be billed to me at the address identified above as the ACCOUNTADDRESS for this site. I <br /> also certify (fiat all information provided on this application is true and correct; and that all regulated activities will be performed <br /> fu accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or FEDERAL Laws <br /> and Regulations. <br /> APPLICANT NAME(Please Print) SIGNATURE <br /> TITLE pRIVER'S LICENSE>f <br /> (PHOTOCOPY REQUIRED) <br /> Approve By Date Accounting Oflice Processing Completed By Date <br />