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n 10-07-1996 10:_6AP1 FR011 p <br /> SAN JOAQUIN COUNTY . PUBLIC HEALTH SERVICES ♦ ENVIRONMENTAL HEALTH DIVISION <br /> FORM (EM 0015(REvISCD tO/OZ/Be) <br /> OATS MASTERFILE RECORD INFORMATION _ <br /> OwNexiD'V CAII V' <br /> OWNER FILE <br /> COMPLETE THE FOLLOW/NG BUSINESS OWNER /NFORINAT/0N.' CNE°KI&F OMERCiwRENRrorvejeewirnEHD <br /> ...................................................................,................................................................................................................................-------........................._............................ --...___.__. .. <br /> BU$INE$8 OWNER PHONE <br /> NAME _________________�___.'__--.`-------_---r�---( <br /> >..-_........__-...._..........................................FtMi..........................-............M(..............................................bRf.(......................................' I:) I �� <br /> Z <br /> BUSINESS NA (i lrtgsr�t hone Ow Name) SOC SEc/TAx 0• <br /> OWNER HrADDRESS �- ORrvCR's LlcersES <br /> City STATE izip <br /> CIO <br /> OwNERMAILimaADORE88 KDIFFERENThun OwnsrAddrsas AAAf vfion:orC evof(vPyanal) n <br /> Mailing Address City state T_1p <br /> TY►E OF OWNERBHIF: <br /> CORPORATION INOIVIDUAL 0 PARTNERSNiP❑ LocAL AcEN11 COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER In <br /> FACILITY FILE <br /> FACILITY ID II .CRosa REF ID V".',. ACCovwT ID A. <br /> COMPLETETHEFOLLOW/NG BUSINESS FACILITY /NFORINATION_ <br /> Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DNisION? YES ❑ NO ❑ <br /> FS this an FASTING Business LocATKm but a NEwTYPE of regulated Business? YES O No O <br /> SUNNEs ACIUTY NAME(Ts WILL sE THE NAME ON HEALTH PERMIT) <br /> FAlba"ACILITY ADDRESS(IFFACILITYISA Aa"FOOD UAYTac Fow V.C1.1 ECQM1 pWWA9MMW $UnEll SUetW88 PHONE <br /> CITY 1FFACfurrigAMoei foonUmToRF000Venrcr�usr i STATE W <br /> BOAROOF SUPER OR MSYRICY LOCAt14R CODE Key-$ I(CYl <br /> Mailing Address fbrNeslrl'e Farm1f M01FFERENrrhorD FaeH/tyAddreas Ag ration•or Caro Of(oPAwmi) <br /> Mailing Address City STATE ZIP <br /> I SIC CODE APN>X CDMIENI <br /> THIRD PARTY BILLING INFORMATION: Complete if Billing Party is different from Business Owner Identified above. <br /> .................................................................................... ............................ . ... ........................ ...................................................................I..........I...........--- •• ---------------- <br /> Sus+NEssNAME + yA"ention:orCersOf( �� 1 ` 1 <br /> �1C.LQ,� l.. t l Y►tKrr11< C__i1�1.1N <br /> Mailing Address {- t� PHOS <br /> Cm t <br /> for fees and charges OWNER ❑ FACiuTYBUSINESS ❑ THIRD PARTY BILLING- <br /> 131LLiNc AND CompLi,%Nc`,Acx,NowLEDG..M&NT: T,the undersigned Applicant,certify that I am the Owner, Operator,or Authorized <br /> Agent of this Business, and I acknowledge that all PEMWIT FEES, PENALT1Es, EXFORCF.A F-N7 CHARGES and/or HOURLY CHARGES <br /> associated with this operation will be billed to me at the address identified above as the ACCOUNTADDRESS for this site. I also certify <br /> that all information provided on this Application is true and correct; and that all regulated activities will be performed in <br /> accordance with 211 applicable SAIN JOAQUIN COUNTY Ordinance Codes and/or Standards d STATE and/or FEDERAL Laws and <br /> Regulations. 1 <br /> Pl£AaE PRINT /` <br /> APPLICANT NAME 7 � SIGNATU 1 <br /> Kic14 n J C 1� L <br /> TITLE C� y. L N('')'ry tC 9 DRIVER'S LICENSE• <br /> (PHOTOCOPY REQUIRED) <br /> i7a <br /> Approved By b Aocaunting Office Pi ecessinp ComPbeted Sy �� /O' �D �6 <br />