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SAN JO>.wUIN COUNTY ENVIRONMENTAL HEALTH Dvt.ARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> 5HADEDSECD0NSFoRfHDUSE0NLy OWNER ID# <br /> OWNER FILE <br /> COMPLETE THEFOLLOW/NG BUSINESS OWNER/NFORMAT/ON.- CHEc/f iF OWNER CuRRENrt yo1vFiLE wiTH EHD❑ <br /> BUSINESS BO PHONE: <br /> OWNER'S NAME <br /> First MI Last <br /> BUSINESS NAME(If ddrerenttmm Owner Name) SOC Sao or Tax ID 9 <br /> OWNER'S HOME ADDRESS �� `-- ,^c:L� pT lr -- Jct c• i F"e- Loc) <br /> CITY C C A E ZIP SZC7 <br /> OWNER'S MAILING ADDRESS(If different from Owners Address) Attention orCare of <br /> MAILING ADDRESS CITY $TATE ZIP <br /> TYPE OF OWNERSHIP: <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP El LOCAL AGENCY❑ COUNTYAGENCY❑ STATE AGENCY FED AGENCY F-1 OTHER❑ <br /> FACILITY FILE <br /> FACILITYIDML2. )_. ;? CO-OWNERID#: ACCOUNTIDM -lei) <br /> COMPLETE THEFOLLOw/NG BUSINESS FACILITY/NFORMAT/ON.' <br /> Is this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES NO ❑ <br /> Is this an ExISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ NO <br /> BUSINESS/FACT ITY NAME(This will be the biusnvEssNAmEonthe HEAL "PERMIT) .7 <br /> FACILITY ADDRESS(HFACI m is a Mo /LEFOOo uN/Tor FOOD YEH/CL£ase the COMMISSARY ADDRESSBUSINESS PHONE <br /> CITY(If FACx/IY Is a MOB/(£FOOD UMTOr FOOD VEHICLE use the COMMISSARY CITY' STATE ZIP <br /> O <br /> BOARD OF SUPERVISOR DISTRICT LOCATIONCODE SfY KEY1 KEY( <br /> MAILING ADDRESS for Healt/1 Pemfi(If OIFFERENTf om FacddyAddress) Attention o,Ca.Of <br /> ff <br /> MAILING ADDRESS CITY STATE ZIP <br /> R <br /> SIC CODE: APN#: I COMMEM: <br /> ACCOUNTADDRESS for fees and charges: OWNER ❑ FACILITY/BUSINESS ❑ <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,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 to me at the <br /> address identified above as the ACCOUNrADDRESS 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 and/or Standards and STATE and/or FEDERAL <br /> Laws and Regulations. <br /> APPLICANT'S NAME: SIGNATURE: <br /> Please Print <br /> TITLE: DATE DRIVER'S LICENSE# <br /> PHOTOCOPY REQUIRED <br /> Approved By Dale Accounting Office Processing Completed By Data <br /> 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 <br /> except UST Program(Use SW RCB forms) <br /> EHD 48-02-035 Masterfile Record-Green <br /> 11/27/07 <br />