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SAN JOAQUIP' `MNTY PUBLIC HEALTH SERVICES -ENVIRONMENTAI "�ALTH DIVISION 1� <br /> MASTERFILE RE _ JRD INFORMATION FORM _H 00 1 5(Revised 6194)} <br /> New Facility1 11 Under Construction Date 95 <br /> SHADED SECTIONS FOR LOCAL USE ONLY OWNER FILE INFORMATION <br /> =OWNER ID # CASE CHECK BOX IF OWNER ON FILE <br /> Please complete the following facility OWNER information: <br /> Owner Nome C 1THome Phone <br /> )/ pr S T OCKTOnI <br /> Owner DBA(if DIFFERENT from Owner Name) Business Phone <br /> Owner Address <br /> City Stated Zip <br /> S-1-0 CKTD7J <br /> Mailing Address <br /> if DIFFERENT from Owner Address H/q R 2 ll <br /> _- - Li 26 WO <br /> Care Of or Attention /�, /) p <br /> (optional) 7J GR�' f-f r �N ,ROU — <br /> Zi <br /> ivlailrng Andress Cir y State <br /> �gtAl�- / <br /> lfff!-de Type of Owner Business <br /> FACILITY FILE INFORMATION <br /> FACILITY ID # ACCOUNT ID # . <br /> . ........................ .. ................................. ................ <br /> Please complete the following FACILITY information: <br /> Facility/Business Name(This will be Name on Health Permit) <br /> nz �rr�r�umAn► l��-�- �—�..�. <br /> Facility Address (If FacilitV is a Mobile Food Unit or Vehicle-See below) Business Phone <br /> —� <br /> fSlo) y a� <br /> City / / Stat Zip x(6242 <br /> CENSUS TRACT '. BD OF SUPERVISOR DISTRICT LOCATION CODE <br /> Mailing Address(for Health Permit/ \ <br /> if DIFFERENT from Facility Address I-�q R �� �� 2s RO L-,l AIL) L/V q Y <br /> Care Of or Attention <br /> (optional) L) 6k �RME,�►T�o�- <br /> Mailing Address City v' 1 StateZip <br /> SIC Code Ust Facility Status Code General type of Business at this Business Code <br /> Location <br /> APN # C-0IJ5 Uf-!qBusiness Type <br /> Please complete the following information if Commissary or Operation Location (such as fair or fesbva0 is different from <br /> Facility Address: <br /> Business Name <br /> Address of Operation lone <br /> gqE I S I_A/qb <br /> _ 1f State zip <br /> CENSUS TRACT BD OF SUPERVISOR DISTRICT LOCATION CODE <br /> [Send all Invoices for Permit and Service FEES to: (Circle one OWNER FACILITY/BUSINESS <br /> A PROGRAM EH 00 59 or WATER SYSTEM EH 00 59w form must be completed for each Environmental Health regulated <br /> operation at this LOCATION except UST Program (Use SWRCB forms) <br /> ecelved by Date - Reviewed by Data Acco", f Qa:'i -c ptti. Unit C At ate Urilt Staff Data - <br />