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SAN JOAI _-,N COUNTY ENVIRONMENTAL HEALTH DE,.,,tTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> SHADED SECTIONS FOR EHD USE ONLY OWNERID# owoD a x(0(03 DARE# 520aLu/_s� <br /> OWNER FILE _5koc6y 6" <br /> COMPLETE THEFOLLOW/NOBUSINESS OWNER/NFORMATTON: <br /> _ CNELN/F OWNER CURRENfLYON F/LEW/T//EHD❑ <br /> BUSINESS <br /> OWNER'S NAME PHONE: <br /> First MI _ Last 70 <br /> BUSINESS NAME(if dillerentfro Owner Name) Soc Sec or`r x 10# <br /> 111 <br /> OWNER'S HOME ADDRESS ST_ <br /> CITY UT `Sf zip 9 �S7 <br /> OWNER'S MAILING ADDRESS(if dNferent Irom Owner's Address) Attention orcare of <br /> MAILING ADDRESS CITY Sr I A ✓'F A TATE LP p,f,S <br /> 74 <br /> TYPE OF OWNERSHIP: _(7 <br /> CORPORATION INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FAdIJtt fD#: Ca /3 6e6rnaER-Ipy/- ACCOUNT ID#: o D 31f o jI <br /> COMPLETE THEFOLLOHI BUSINESS FACILITY/NFORMAT70N: 29 b5 <br /> [is this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENr7 YES ❑ NO <br /> S this an EMSTING Business LOCATION but NEW TYPE of regulated Business? YES ❑ NO SLR <br /> BUSINESS/FACILITV NAME his will be the BtrsrWEssNANEon the HEALTH PERMIT) <br /> FACILITY ADDRESS IN if; <br /> a MOB/LEF000 UNfrorF Hle se the CoumssaxYADwtEssl 7;8USINESSPHONE <br /> /�SG67 N. Tr}coc3 624C,CIt <br /> SN;a# <br /> CITY(If FAMUTrls a Mos,L F000 UNror Foca VEHIaLBuse the CmiessARY Om) =STA�TE zip <br /> S <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> MAILING ADDRESS fOrHe9/f/7PennII If D/FFERENTfrom Fa &yAddmss) Attention crCare Of <br /> wts S L (11G 16 N <br /> MAILING ADDRESS CITY Po Q C% 2Lt� S� „ELJ <br /> J/�-J STA�A Zip <br /> SIC CODE: APNL#:C 1 I -Og0 -0 J Couaer: Yl J <br /> ACC01#k?ADDRE5 for fees and charges: OWNER ❑ FACILITY/BUSINESS <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that 1 am the Owner,Operator,or Authorized Agent of this Business,and <br /> acknowledge that all PERM/T FEES, PENALrEs, 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 all <br /> regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or FEDERAL <br /> Laws and Regulations. <br /> AL <br /> APPLICANT'S NAME: L I q NATURE: <br /> P ease Print <br /> TITLE: DATES 2� PHIVER'S LICENSE If OTOCOPY REQUIRED 0 <br /> Approved By Date Accounting Office Processing Completed By �f ! Data <br /> A PROGRAM(EHD 48-02-034 Pink}or WATER SYSTEM(EHD 48-02-003)form must be completed for each EHD regulated-operation at this LOCATION <br /> except UST Program(Use SWRCB forma) <br /> EH048-02-035 Masterfile Record-Green <br /> 11127107 <br />