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umniuis <br /> MASTERFILE II' ECORD INFORMATION FORM {EH 01 15a <br /> New Facility Under Construction Dete <br /> sHA ED $ECT/ONS FOR LOC EX [HE E <br /> [5 WNER ID # SASE # HEcx WNER ON FIU <br /> Pleaa complete the following facility OWNER information: <br /> O or Name Home Phone <br /> O er DBA(if DIFFERENT from Owner Name/ Business Phone <br /> O er es hands oroug y <br /> :::] <br /> I <br /> State Zip <br /> FF Te o;inse, and sanitize all utensils between <br /> C4 <br /> D Of or Atlelac h use i o <br /> to 'oval) Q <br /> n <br /> Mi ling Address City E __ Stets Zip <br /> $ ineas a de Type of Owner Business <br /> V `'M <br /> FACIL ID # ACCOUNT ID # <br /> Pie a com 1p��Uafj"Ofaatilnt?s-rhal temperature ' <br /> Fs, ility fBuelnv f al&34 bums on Health Pernrt/ <br /> F4,jility Address lff Facility is s Mobile Food Unit or Vehicle-See below/ Businese e <br /> • Kee h ' <br /> � <br /> Cx IState y� <br /> Kee cold foods refri ° <br /> CENSUS'TRACT BO OF SUPERVISOR-DtSTRIC7.. 9 .LOCATION ODE <br /> "ng"d a"(for Health Permit) <br /> i IFFERENT from Facility Address <br /> e ARefrigerate foods that spoil easily, <br /> r t%Or <br /> ling Address City State <br /> IF <br /> et Fecii' y St ue Code General type of Business at thisBusiness Code <br /> o oon as ossible Business Type <br /> a complete the following information if Commissary or Operation Location (such as fair or f-ctiva/1 is different frorFiAddress <br /> 4-in a165° <br /> dress of Operation ne <br /> 4)f 165° State TP <br /> Jr ENSUs.TRACT i:BD OP6SUPERVISOR DtS'RtCT LOC»TION.CODE <br /> nil[ i J, —, OWNER FACILITY/BUSINESS <br /> A ROG r R T st be completed for each Environmental Healtt <br /> re lated operation at this LOCATION except UST Program (Use SWRCB forms) <br /> vea Y to vuw by r• oountln0 tfwe ate. t ar1t. t• Unt lore •u <br />