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SAN JOAQUIN COUNT PUBLIC HEALTH SERVICES • ENVIRONML HEALTH DIVISION <br /> FORM (EHM15(REVISEDIOM2/96) <br /> DATE MASTERFILE RECORD INFORMATION ` „ <br /> SmoED SFcnow FOR ENO USE ONLY OWNERID#'. ILs,' CASE# IvYL/, <br /> OWNER FILE <br /> COMPLETETHEFOLLOWING BUSINESS OWNER INFORMATION: CHEcKlF OWNER CURREN YONFkEwImEHo <br /> ..................................:...........................................................................................................................................................................,........................................................................................ <br /> . <br /> i BUSINESS OWNER PHONE <br /> NAME ------------------------------------------ <br /> ...................................................................Ent........................................Mt..............................................Asst......................................` <br /> BUSINESS NAME(If different Ircro Owner Name) SOC SEC I TAa ID# <br /> OWNER HOME ADDRESS DRIVER'S LICENSE# <br /> CRY STATE ZIP <br /> i OWNERMAILINOADDREss ifDIFFERENTfrom OWn&rAddreas Attention:arcane of(opflonal) <br /> i Mailing Address City State i Zip <br /> TYPE OF OWNERSHIP: <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ QTH ER❑ <br /> FACILITY FILE <br /> FACILITY ID# IoC JT''.55..'�. I <br /> I CROSS REF ID# ACCOBNT ID# <br /> COMPLETETHEFOLLOW/NG BUSINESS FACILITY INFORMATION: <br /> Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DIVISION? YES ❑ NEOIs this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES <br /> BUSINESsIFACILnY NAME(THIS WILL BE THE NAME ON HEALTH PERMIT) <br /> Cal —Farm Sugoly Cnm}many . Tnr _ <br /> FACIUw ADDRESS#FFACIUrrISA MOsllfFboa UMTm FOOD VEHcC USECOMMIss"Y ADDRESS) Sum# BUSINESS PHONE <br /> ?n4o West WashinaF.On Street <br /> CITYIFFAciu"ISAAfbaiEFOODUmrT FOODVOtlCLE COMWSSARYADDRgn QW) STATE ZIP <br /> Stockton CA <br /> SOARDOFSUPERVISORDISTRICT LOCATIONCODE I(EYf KEY1 <br /> i Mailing Address for Health Permit dDIFFEREWTfro FacilityAddresv Attention:or Care Of(optional <br /> Mailing Address City STATE ! ZIP <br /> SIC.CDOE APN# CoialEwT <br /> THIRD PARTY BILLING INFORMATION: Complete tf Billing Party is different from Business Owner ideniifled above. <br /> ................................................................................................................................................................................................................................................................................. . <br /> BUSINESS NAME Attention:or Care Of(opffonatl <br /> Martha Bowman, Trustee in Bankruptcy <br /> Mailing Address PHONE <br /> P.O . Rox 570 ( 916 )497-1141 <br /> C" Penryn CA TE zip 95663 <br /> ACED LMEADDRESS for fees and charges OWNER ❑ FACILITY/BUSINESS ❑ THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I, the undersigned Applicant, certify that I am the Owner, Operator, or Authorized <br /> Agent of this Business, and I acknowledge that all PERMIT FEES, PENALTIES, ENFORCEMENT CHARGES and/or HOURLY CHARGES <br /> associated with this operation will be billed to me at the address identified above as the ACCOUNTADORESS 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 all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and,STATE and/or FEDERAL Laws and <br /> Regulations. <br /> PLEASE PRINT , \ <br /> APPLICANTNAME Martha Bowman SlNAT R <br /> TITLE Trustee in Bankru,3tcy DRIVER'S (CENSE# <br /> (PHOTOCOPY REQUIRED) <br /> Approved By . Date Accounting Office Processing Completed BY; 55 Date05 IS19 <br />