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0 <br /> r SAN JO N COUNTY ENVIRONMENTAL HEALTH bi- RTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> SHADEASECTIONSFOREHDUSEONLY OWNER ID# CASE# ° <br /> OWNER FILE <br /> COMPLETETHEFOLLOw/NGBus INESS OWNER INFORMATION.' CHECKIF OWf ER CURRENTLr0NFUEw1THEHD0 <br /> BUSINESS In/1 E, <br /> "'N� PHONE: <br /> First ©� <br /> OWNER's NAME 1 loll <br /> ' n4P 1 <br /> Mr Last � `� <br /> BUSINESS NAME If differentfrom Owner Name) SOO SEC orTax ID# <br /> J o ad r l` a' b 1 S <br /> OWNER'S <br /> HOME <br /> ADDRESS <br /> CITY Sq JD ! . VV vVdr ; <br /> c/ i tAA <br /> ZIP 1?5',7, �o <br /> OWNERS MAILING ADDRESS (If different from Owner's Addre Attention orCare of <br /> PO `tjo l a_6 v .I <br /> MAILING ADDRESS CITY W I O``-f'`„� ]b ZIP C7`Jr�Shy�J <br /> TYPE OF.OWNERSHIP; [� (;� I <br /> CORPORATION INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> a <br /> FACILITY ID#: � Lk lk .3 CO-OWNER ID#::.'J, ACCOUNT ID#: a�'b(j�:�` 2 S <br /> COMPLETETHE FOLLOwwG BUSINESS FACILITY INFORMATION.' I <br /> Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO <br /> x <br /> - Is this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ NO <br /> BUSINESS/FACILITY NAME(This will be the 8USINESSNAREnn the HEALTH PERMIT) h <br /> FAJ�CILptT/rSA�QQRESS(If Facrurrisa MoercEF ooU UNrror soonEmcLE[7(�Jthe COMMISSARY AooREss) BUSINESS PHONE <br /> I ' <br /> lLj QrDC /7rCSuite 1 ' G-J <br /> 44 <br /> CITY(If FACILJTYIS a MOBILE F000 VNITor Foos VEHICLE use the CommiSSARY C{TY) STATE r ZIP <br /> 2- 2 a <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> MAILING ADDRESS for Health Perm t(If DIFFERENTfrom FacilityAddresa). Attention orGare Of <br /> Off <br /> ) . Y, d `1 1 Wl l�.�ll"�AAIDF_Lt— <br /> MAILING ADDRESS CITY / r� _j / STATE . ZIP ��Z <br /> SIC COOE APN#(:� (�( `COMMENT: <br /> AC OKMATADDRESS forfees and charges: OWNER ❑ FACILITY/BUSINESS K <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I <br /> acknowledge that all PERMIT FEES, PENALTIES, ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this Operation will be billed t0 me at the <br /> address identified above as the ACCOUNTADDRr=SS for this site. I also certify that all information provided on this application is true and correct;and that all <br /> regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes andior Standards and STATE andlor FEDERAL <br /> Laws and Regulations. <br /> APPLICANT'S NAME: %:j C R,41�[�� I/ SIGNATU <br /> Pease Print <br /> TITLE: J J_ DATE l� j� Q C} DRIVER'S LICENSE# <br /> e L 1 f tS 1PHOTOCOPY REQUIRED <br /> Approved By , Date Q Aacoutiting Office Processing Completed By -Ar? Data l (� <br /> l <br /> A PROGRAM(EHD 48-02-034 Pinky or WATER SYSTEM(EHD 46-02-003)form must be completed for each EHD regulated operation at this LOCATION <br /> except UST Program(Use SWRC8 forms) <br /> EHD 48-02-035 ! Masterfile Record-Green <br /> 11127107 'E <br /> ,I <br />