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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> SHADED SECTIONS FOR EHD USE ONLY i CAS <br /> E, # <br /> # <br /> E# <br /> .,.: <br /> ,c �- <br /> OWNER FILE <br /> COMPLETETHEFOLLOWINGBUSINESS OWNER INFORMATION: CNECKIF OWNER CURRENTIYON FILEWrMEHD❑ <br /> BUSINESS t Z PHONE: <br /> OWNER'S NAME c.J v1 Fitt M! Last 2 0 F 6� � 7e:_-17r <br /> BUSINESS NAME(If d/fierentfrDmowner Name) Soc Sec orTax.ID# <br /> e � t`11-I1 LL< <br /> OWNER'S HOME ADDRESS I 3 g ch <br /> 4A eel <br /> CITY / STi ZIP Ll <br /> L i `7 <br /> OWNER'S MAILING ADDRESS (If dtlerentfromOwnees Address) Attention orCare of <br /> o00a `79� <br /> MAILING ADDRESS CITY j �I STATE [ <br /> 4 <br /> ZIP <br /> TYPE OF OWNERSHIP: !_ 7 <br /> CORPORATION❑ INDIVIDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER <br /> FACILITY FILE <br /> LFACILIfi' <br /> COMPLETE THE FOLLOWINGBUSINESS FACILITYINFORMATION: <br /> Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES Cq No ❑ <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No <br /> BUSINESS/FACILITY NAME(Reis will be the BUSINF55NAmEon the HEALTH PERMIT) J -;._ q <br /> lO /I L LC <br /> FACILITY ADDRESS(If FACttrnris a MOBILEFOAX UNU7or Fc oD YsiraEuse the QpMMIS y ADaREsslBUSINESS PHONE <br /> 14 1L., ry <br /> tNumber�� tJr s ,06"" <br /> d W t TAve Suite# <br /> CITY(IfFACILf7YlsaMoa DUWTorFb-o-f3 cormmswyCirri STALES ZIP <br /> UFl_ � ff <br /> BQARDOFSIIPERVLSOADIS171IGTb m ;LOCATION CODEI ICEY9 �9xre w � Y ei c' i s <br /> mom. ...,._ ... ....,..,.�-, <br /> MAILING ADDRESS for Health Permit'(If DtFFERENTfrom Fadl/t)'Address) Attention orcare of <br /> c d <br /> MAILING ADDRESS CITY <br /> L p E ZIP <br /> 4 c� 95211 <br /> SlCCooE $ f £ API\ <br /> <.< °'#, <br /> for fees and charges: OWNER ❑ FACILITYIBUSINESS <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and <br /> I acknowledge that all PERMIT FEES,PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this Operation will be billed to me at the <br /> address identified above as the ACCOUNTADDREsS for this site. I also certify that all information provided on this application is true and correct;and that <br /> all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/Or Standards and STATE and/or <br /> FEDERAL Laws and Regulations. <br /> APPLICANT'S NAME: p�P y SIGNATURE- / <br /> Please Pant <br /> TITLE. DATE DRIVER'S LICEN E# <br /> I PHOTOCOPY REQUIRED) 0 � <br /> . Approved BY Date , <br /> Aamarrting Office ProtcssIng Com{feted By 1 Ddte <br /> i A PROGRAM {EHD 48-02-034 Pink} or WATER SYSTEM {EHD 46-02-003)� � � � � <br /> ,. <br /> form mus be completed for each EHD regulated operation at this <br /> LOCATION except UST program(Use SWRCB forms) <br /> EHD 48-02-035 <br /> 8/19/08 Mastefile Record-Green <br />