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eSAN JOAQUIN COUNT` ♦ PUBLIC HEALTH SERVICES • ENVIROI �'NTAL HEALTH DIVISION <br /> til %-"* FORM {EH0015(REw3ED10102198} <br /> DATE I i MASTERFILE RECORD INFORMATION <br /> 5/�li 00SFC77ONSFOREHU Ust QIt9 Y � ; CnwNEit1f}�B :: :.,�c�:��: a(: CASE <br /> OWNER FILE — --` <br /> COMPLETE THE FOLLOW/NGBUSINESS OWNER INFORMATION: CHEcx,F OWNER CURRENTLYONFILE WITH EHD <br /> ........ .............. <br /> BUSINESS OWNER PHONE <br /> NAME ———— -.—...-.__,......-- ----_..— <br /> ..............- F <br /> ---*..................._._......._._..._......_... w . <br /> ......._.._..........MI ...............4ast.__..._.._..........._.._...._._......' <br /> Busrwss NAME(if different from Owner Name) ? S0C SEC!TAX ID# <br /> OWNER HOME ADDRESS DRIVER'SLICENSE# <br /> city STATE ZIP <br /> OWNER MAILING ADDRESS If DIFFERENT from OsmerAddrvw c Atfiention:orCare of(opt/anal) <br /> `• Mailing Address City r�� i Statv+ � Zip <br /> TYPE OF OWNERSHIP: ^'�• �} <br /> CORPORATION i' INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FAciuTY IDS CROSS REF ID#: I: 1 r :ACOOIlNT`ID.lR :. <br /> COMPLETETHEFOLLOW/NG BUSINESS FACILITY INFORMATION: <br /> Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DIVISIoN? YES ❑ No ❑ i <br /> Is this an E)asTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ❑ <br /> 8usmEssIFACILITY NAME(Tits WILL BE THE NAME ON HEALTH PERMIT l <br /> FACILITY ADDRESS(IF FACIIITYISANbmLEFOOD UAVroR Fow VEHICLE USE CommssARY ADDRESS SUITE BUSINESS PHONE. <br /> CrTY IF FAciurrISA MDHREFDovLlmroR Foon VErncLE UsECOMMIs9ARY ADDRFSSCSTAZIP_ <br /> / -7 E:r, 3 <br /> BOARD OF SUMRVISORDISSRICT- 7. 1.L—A-1 CODE: I tCCY'I- ... ::::::: ::: :.1.-,KCY2'; .1 <br /> i <br /> ! Mailing Address for HesIMPermit /fDIFFERENTfrom sci/ilyAddress i AtIention:orCare Of(optiona/J <br /> Mailing Address City i/ i STATE E LP <br /> �I <br /> a ' - <br /> SI£CanE APNA : L;OMNE!!i":.. _ _. <br /> L___�_—_.—_ .. .. ... - .. .. -. ... . — <br /> ,'THIRD PART BILLING INFORMATION: Complete if Billing Party is different from Business Owner/denied above. <br /> 4................... �` --------.._.._...... ---------... --- ................................................................................................. <br /> ..........., <br /> laslss#IAMEi Attention:arcane Of ( ! <br /> Mailing Address 1�. PHONE <br /> CnY STA <br /> zip <br /> ACCOUNTAIDDRESS for fees and charges OWNER FACIUTYIBUSINESS ❑ THIRD PARTY BILLING ❑ <br /> BILLING,1 ND 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, PEXALTIES, ENFORCEMENT 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 all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or FEDERAL Laws and <br /> Regulations. <br /> PLEASE PRINT - fff � ,�F <br /> APPLICANT NAME i�i�n� SIGNATURE /f/�C:/��"'� //X�/�r�p <br /> TITLE ^� DRIVER'S LICENSES <br /> (PHOTOCOPY REQUIRED) <br /> Approved By Date Accounting Office Processing Completed <br />