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^ SAN JOAQUINr LINTY PUBLIC HEALTH SERVICES -ENVIRONMENTAL HEALTH DIVISION T9 If " �I / q (t/ <br /> MASTERFILE RE6RD INFORMATION FORM f-I 00 15(lievised6194)) <br /> New Fec'fty Under Construction Date <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 Nemy Home Phone <br /> Owner DBA(if DIFF RENT from Owner Name) Business Phone <br /> amt- 599- 2-1 ®8 <br /> Owner Address <br /> 2S�f I�Jo2-T7-{ 1 ijwir- Ach ctE— <br /> Cit S ata zip <br /> y I T'OM �!4 - QS jlo h <br /> Mailing Address <br /> if DIFFERENT from Owner Address <br /> Care Of or Attention »� <br /> (optional) mfe— ���� � <br /> Mailing Address City State Zip <br /> �— <br /> f Businea9 Code !. Type of Owner Business <br /> FACILITY FILE INFORMATION ' <br /> FACILITY 1b # r G ACCOUNT ID # YI <br /> Please complete the following FACILITY information: <br /> Facilhy/Busine a Name(This will be Name on Nee/th Permit/ <br /> "7/ L OF Z� <br /> Facility Address (if Fac ity is a Mobile Food Unit or Vehicle-See below) Business Phone <br /> /o2/0 5� &az<+ Ave du-E, aW-599- Zi08 <br /> City State Zip <br /> el 5-3(o� <br /> CENSUS TRACT BD OF;ISUPERVISOR DISTRICT I' LOCATION CODE <br /> Mailing Address(for Health Perm III <br /> if DIFFERENT from Facility Address <br /> Care Of or Attention <br /> (optional/ <br /> Meiling Address City State Zip <br /> 'SIC Code Usk Facility Status:Code General type of Business at this Business Code <br /> Location <br /> APN A Business Type.. <br /> Please complete the following information if Commissary or Operation Location (such as fair or fesdva/I is different from <br /> Facility Address: <br /> Business Name <br /> Address of Operation Phone <br /> City State Zip <br /> :'.CENSUS TRACT. BO OF SUPERVISOR DISTRICT TION CODE <br /> Send all Invoices for Permit and Service FEES to: (Circle one OWNER FACILITY/BUSINESS <br /> A PROGRAM EH 00 591 or WATER SYSTEM EH 00 59—wl form must be Com eted f each Environmental Health regulated <br /> operation at this LOCATION except UST Program (Use SWRCB forms) <br /> Rocalved by gas, R.vi.odl by pts Aca.mAfirl Iffie., 1 ate Un!tC[.'kL Dot. unitgrantp[@ <br />