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Iqe_�ncvJc .0 be_AeAe(,ds.(,L),, SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT I MASTERFILE RECORD INFORMATION FORM j�,�pci� b"�eKpficc+s cc:•�A SHADED SEC77ONSFOR EHD USEONLY OWNER ID# CASE# OWNER FILE COMPLETE THE FOLLOW/NG BUSINESS OWNER /NFORMAT/ON: CHECKIF OWNER CURRENTLYONFILEw/THEHD❑ BUSINESS OWNER'S NAME FACILITY ADDRESS (If FAC/L/TYIS a MOBILEFOOD UNITOr FooD VEHICLEuse the COMMISSARY ADDRESS) Suite # PHONE: `�,� / `- OCC -14 First M/ Last BUSINESS NAME (If different from Owner Name) 1 T G k \° �t0 S ro C, b S � N C Soo Sec or Tax ID # OWNER'S HOME ADDRESS CITY STATE ZIP OWNER'S MAILING ADDRESS (If different from Owner's Address) Attention orCare of MAILING ADDRESS CITY STATE ZIP TYPE OF OWNERSHIP: CORPORATION INDIVIDUAL ❑ PARTNERSHIP ❑ LOCAL AGENCY ❑ COUNTY AGENCY ❑ STATE AGENCY ❑ FED AGENCY FACILITY FILE FACILITY ID #: CO-OWNER ID #: ACCOUNT ID #: COMPLETETHEFOLLOW/NG BUSINESS FACILITY /NFORMAT/ON: Is this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES ❑ NO ❑ IS this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ NO ❑ BUSINESS/FACILITY NAME (This will be the BUS/NESS NAMEon the HEALTH PERMIT) FACILITY ADDRESS (If FAC/L/TYIS a MOBILEFOOD UNITOr FooD VEHICLEuse the COMMISSARY ADDRESS) Suite # BUSINESS PHONE CITY (If FACILITYIs a MOBILE FOOD UNIT or FOOD VEHICLE use the COMMISSARY CITY) STATE ZIP BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEYi FKEY2 MAILING ADDRESS for Health Perm t(If DIFFERENTfrom Facility Address) Attention orCare Of MAILING ADDRESS CITY STATE ZIP SIC CODE: APN #: COMMENT: ACCOUNTADDRESS for fees and charges: OWNER ❑ FACILITY/BUSINESS ❑ BILLING AND COMPLIANCE ACKNOWLEDGMENT: I, the undersigned Applicant, certify that I am the Owner, Operator, or Authorized Agent of this Business, and I acknowledge that all PERMIT FEES, PENALTIES, ENFORCEMENT CHARGES and/Or HOURLY CHARGES associated with this Operation will be billed to me at the address identified above as the ACCOUNT ADDRESS for this site. I also certify that all information provided on this application is true and correct; and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or FEDERAL Laws and Reaulations APPLICANT'S NAME: SIGNATURE: Please Print TITLE: DATE DRIVER'S LICENSE # (PHOTOCOPY REQUIRED) Approved By Date Accounting Office Processing Completed By Dete A PROGRAM (EHD 48-02-034 Pink) or WATER SYSTEM (EHD 46-02-003) form must be completed for each EHD regulated operation at this LOCATION except UST Program (Use SWRCB forms) EHD 48-02-035 Masterfile Record -Green 8/19/08