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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> SHADED SECTIONS FOR EHD USE ONLY OWNER ID III hl. , n�?�! �l-� CASE# - <br /> V INOWNER FILE <br /> COMPLETE THEFOLLOW/NG BUSINESS OWNER INFORMATION: 11 CHEcKtF OWNER CuRRENTLroNFtLEwiTHEHD❑ <br /> tom" , t <br /> BUSINESS i ; o- µ (I �vt PHONE: <br /> OWNERS NAME to b -79 <br /> First MI Last <br /> iifi <br /> BUST S NAME(If diffemntfrom Owner Name Soo Seo or Tax ID# <br /> Q vill set. 'o ALA--� o 2 !�c <br /> OWNER'S HOME ADDRESS 33 2 t�2 YO ip c.- Ie- <br /> CITY Iwil STAT ZIP <br /> OWNER'SMAILING ADDRESS (If different from Owner's Address) Attention or Caref <br /> '3 3 2 I/zctir 1. ;,C�_ A L ti <br /> MAILING ADDRESS CITY Mo-v4--e- STS. ZIPpS-y__6 <br /> TYPE OF OWNERSHIP: C- / <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID#: DQ CO-OWNERID#: ACCOUNTID#: oa -7�o <br /> COMPLETE THEFOLLOW/NG BUSINESS FACILITY INFORMAT/ON: <br /> Is this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES ❑ NO ❑ <br /> n�o.....­,ro <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ❑ <br /> BUQIl1ESS/FACILITY NAME(T is will be the SuslmEsS NAMEon the HEALTH PERMIT) <br /> �TC7 Wl 4-�✓� <br /> FACILITY ADDRESS(If FAcalTrie aMDa2EFooDUN ZOr FOOD VEHICLEUSe the COMMISSARY ADDRESS) BUSINESS PHONE <br /> .. Z1 64 F-• Ckev-aK e —a 017)-12-/ <br /> Suite# <br /> ClN If FACILITYIS MOBILE FOOD UNIT Or FOOD VEHICLE use the COMMISSARY CITY) STATE ZIP <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> MAILING ADDRESS for Health Permilt(If D/FFERENTfrom FacililyAddross) Attention orCare Of <br /> 'Pa A �/�tiz � �ivt <br /> MAILING ADDRESS CINSTAT€ W ZIP 9��. <br /> 4 <br /> ori -C e— C.- <br /> SIC CODE: APN P. COMMENT: <br /> ACCOUNTADDRESS for fees and charges: OWNER FACILITY/BUSINESS ❑ <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 WIII 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: SIGNATURE: <br /> Please Print <br /> TITLE: DATE DRIVER'S LICENSE# <br /> PHOTOCOPY REQUIRED <br /> Approved By Date Accounting Office Processing Completed By Date 37T TI <br /> A PROGRAM(EHD 48-02-034 Pink)or WATER SYSTEM(EHD 48-02-0031 form must be completed for each EHD regulated operation at this LOCATION <br /> except UST Program(Use SWRCB forms) <br /> EHD 48-02-035 Masterfile Record-Green <br /> 8119108 <br />