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SAN JOAO("" COUNTY ENVIRONMENTAL HEALTH DF-1RTMENT R(MSTERFILE RECORD INFORMATION FORe SHADED SECTIONS FOR EHD USE ONLY OWNER ID# b� Qb..�-�d�s CASE# OWNER FILE COMPLETE THEFOLLOw/NG BUSINESS OWNER INFORMATION: CHECK 1F OWNER CURRENTLYON FILE wiTH EHD❑ BUSINESSI PHONE' Aa First OWNER'S NAME Last R� a -Asia MI BUSINESS NAME(If different from Owner Nnrame) Soc See orTax ID# I V OWNER'S HOME ADDRESS I3,2,SS M,dowl Dr. /]('` ''7 CITY "rte STA4G ZIP q 3 OWNER'S MAILING ADDRESS (If different from Owner's Address) Attention or Care of fill I a"SS 7rtat 13 vd . SLt,re goo MAILING ADDRESS CITY wal 8 wt r enk S(�b TYPE OF OWNERSHIP: CORPORATION INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY OTHER❑ FACILITY FILE �/ FACILITY ID#: D �ID>-r� CO-OWNER ID#: ACC � OUNT ID#: Dq�-ZIOa COMPLETE THE Fou Ow/NG BU SI N ESS FAC I LITY INFORMATION: Is this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES El No [__1nce. Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ❑ BUSINESS/FACILITY NAME(This will be the BUsw s5NANEon the HEALTH PERMIT) e MIA IG �rtC- FACILITYADDRESS(If FAcalrYls a MOaILEFOOD UNITOr F000 VEHicLEuse the C MMISSARY ADDRESS) BUSINESS PHONE a6/0( N, Carol Hito Rcl Suite# CITY(If FAciL is a MOaxE FOOD UMTOr FOOD VEHICLE use the COMMISSARY CIN) STATE zip Ram q n4 BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEYt KEY2 MAILING ADDRESS for Health Permlf(If D/FFERENTfrom FaciiityAdOmss) Attention orCare Of MAILING ADDRESS CITY STATE ZIP SIC CODE: APN#: COMMENT: ACCOUNTA2VEESSfor 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 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. Cfe,Ap 11ac J t utd fwv -h;llab�C r F Op�33� APPLICANT'S NAME: SIGNATURE: Please Print TITLE: DATE DRIVER'S LICENSE# PHOTOCOPY REQUIRED Approved By Data Aeceuntlng Offlce ProceaaIng Completed By 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 8119108