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SAN JOP IIN COUNTY ENVIRONMENTAL HEALTH nGPARTMENT -MASTERFILE RECORD INFORMATION F(nclJl SHADED SECTIONS FOR EHD USE ONLY CWNER ID# CASE# OWNER FILE COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION: CHECK IF OWNER CURRENTLY ON FILE WITH EHD❑ BUSINESS PHONE: OWNER'S NAME First MI r7777Last BUSINESS NAME(If different from Owner Name))+ SGC See or Tax ID# OWNER'S HOME ADDRESS CJ' om CIN STATE ZIP S l OWNER'S MAILIN6 ADDRESS (If differentfrom Owner's Address) Attention or Care of 2 6 „e---& MAILING ADDRESS CITY STATE ZIP TYPE OF OWNERSHIP: CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY El COUNTYAGENCY❑ STATE AGENC FED AGENCY OTHER❑ FACILITY FILE G <94t? FACILITY ID#: CO-OWNER ID#: ACCOUNT ID#: COMPLETE THE FOLLOWING BUSINESS FACILITY INFORMATION: Is this a NEW Buslneas LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES NO ❑ nom.,.er..o,Tn I Is this an EXISTING Business LOCATION but a NEINTYPE of regulated Business? YES ❑ No BUSINESS/FACILITY NAME(This will be the BUSINESS NAMEOn the HEALTHPERMIT) _' e -(— FACILITY ADDRESS(if FActLm is a Mosu Fcoo(UNrrorr FFoco VEHICLE use the CommisssARY A�DD.RE/slsl / BUSINESS PHONE � S3 �IidS SL_ OXY �/j j 2cJa� ri'1 �—J-.F 4o-j.4 T— suite s Zu�l—$33^2vZi CITY(6 FaclL/lY�q.�MOBILE FOOD UNROr FOOD VEHICLE use the COMMISSARY CITY) STATE ZIP C4 9.5;5 7 BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEYI KEV2 MAILING ADDRESS for Health Permit(If DIFFERENTfrom Facility Address) Attention or Care Of MAILING ADDRESS CITY STATE ZIP c SIC CODE: APN#: r��L COMMENT: SII ACCOUNTADDRESSfor 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 WIII be billed tome at the 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 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 Regulations. APPLICANT'S NAME: SIGNATURE: Please Print TITLE: DATE DRIVER'S LICENSE# PHOTOCOPY REQUIRED Approved By Dale Accounting Once Processing Completed By Date 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 81,19108 C '�_ S- /el