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1 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> SHADED SECnONS FOR EHD USE ONLY OWNER ID# CASE# <br /> OWNER FILE <br /> COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION: CHECKIF OWNER CURRENTLY ON FILE WITH EHD <br /> BUSINESS PHONE <br /> OWNER NAME % 2 / <br /> First MI Lasr D JJ <br /> BUSINESS NAME(If dYferent tion owner Name) Sec Sec Or Tax ID# <br /> OWNER HOME ADDRESS <br /> CIT'- STATE Zip <br /> OWNER MAILING ADDRESS(If ditmnt from Owner Address) Attention or Care of <br /> 2.so© Nom!✓ .+? G�i� ��!'([c:t� <br /> MAILING ADDRESS CITY qp Zp�� <br /> TYPE OF OWNERSHIP: C�— <br /> CORPORATION❑ INDMDUAL❑ PARTNERSHIP❑ LOCAL AGENCY COUNTY AGENCY❑ STATE AGENCY❑ Feb AGENCY El OTHER❑ <br /> FACILITY FILE <br /> FACILITYID#: T CO-OWNER ID#: I ACCOUNT ID#: <br /> COMPLETE THE FOLLOWING BUSINESS FACILITY INFORMATION: <br /> IS this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO ❑ <br /> Is this an ExISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ NO ❑ <br /> BUSINESS/FACILITY NAME(This will be the Bu9NEss NArEon the HEALTH PERMIT) <br /> FACILITY ADDRESS(IfFnaurrIs a MOalLEFOOD UN or FOOD VE iI use the COMuissA_Y AnneRssl BUSINESS PHONE <br /> CITY(IfFAcwrYis a Mo&LEFOoD UNnor FOOD VEHICLE use the C.nmw.ccARYQ ) STATE ]gyp <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEYI KEY2 <br /> MAILING ADDRESS for Health Perflllt(If DIFFERENTfmm FadlityAddrass) Alrentlon or Care Of <br /> MAILING ADDRESS CITY 1 STATE ZIP <br /> SIC CODE: APN P. COMMENT:��II <br /> ACCOI HNT AQagf, R for fees and charges: OWNER u� FACIUTYIBUSINESS ❑ <br /> R11 INC. AND f OMRr.IANCR ACKrvowr.r.DCMFNT: I, the undersigned Applicant, certify that I am the Owner, Operator, or Authorized Agent of this <br /> Business, and I acknowledge that all PERMIT FEES,PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated With this Operation will be <br /> hilled t0 me at the address Identified above as the ACCOUNT ADDREQQ for this site. I also certify that all Information provided on this application Is true <br /> and correct; and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Re tulations. <br /> APPLICANT NAME: ?qXrrSIGNATURE; <br /> PIe se Print <br /> TITLE: DATE DRIVER'S L CENSE It <br /> Approved By Data Accounting Office Processing Completed By Date <br /> A PROGRAM(EHD 48-02-034 Pink)or WATER SYSTEM{EHD 46-02-0031 form must be completed for each EHD regulated operation at this LOCATION except <br /> UST Program(Use SWRCB forms) <br /> EHD 48-02-035 Masterfile Record-Green <br /> 10/0/2003 <br />