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SAN JOAQUI" COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORrvr.- SHADED SECTIONS FOR EHD USE ONLY OWNER ID# i I 6 00 c)/ OJ� CASE# OWNER FILE V COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION: CHECK IF OWNER CURRENTLY ON FILE WITH EH BUSINESS P/HONE: OWNER'S NAME First MI Last BUSINESS NAME(if different from Owner Name) / Soc Sec or Tax IDIII QMel- mprIIi Gvv-) elf OWNER'S HOME ADDRESS P, 0 , CITY b .PN ( x ZIP 010 OWNER'S MAILING ADDRESS (If different from Owner's Address) Attention or Care of MAILING ADDRESS CITY STATE ZIP TYPE OF OWNERSHIP: CORPORATION INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY OTHER❑ FACILITY FILE FACILITYID#: d CO-OWNERID#: ACCOUNT ID III: COMPLETE THEFOLLOWING BUSINESS FACILITY INFORMATION: r--re 10 'U O Is this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES .cY NO ❑ S� ,,Ss a,,! .n Is this an ExISTING Business LOCATION but a NEw TYPE of regulated Business? YES ❑ No BUSINESS/FACILITY NAME ill be the BUSINESS NAMEon the HEALTH PER IT) � � ! �-7 M2�IL N e✓L C�-P FACILITY ADDRESS(if FACILITY is a MOBILE FOOD UNITor FOOD VEHICLE use the COMMISSARY ADDRESS) BUSINESS PHONE /� - I I b1rA,( J QD Suite# 106 ZD -0Z gV CITY(if FACILITYIs a MOBILE FOOD UNITor FOOD VEHICLE use the COMMISSARY ClTY) STATE ZIP ocV1 u A 91,ZIS BOARD OF SUPERVISOR DISTRICT ob Q4 LOCATION CODE KEY1 KEY2 MAILING ADDRESS for Health Perfnit(If DIFFERENTfrom FacilityAddress) Attention or Care Of 01 Qok (0 A10 Ly MAILING ADDRESS CITY PIAO e I \/ STATE /�I �7 ZIP SIC CODE: 1 ApN#: 7`.2 I 0 COMMENT: ACCOUNT ADDRESS 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 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 Date 1 rl ' '( Accoun ing Mee Processing Completed By Date A PROGRAM{EHD 48-02-034 Pink)or WATER(SYSTEM(EHD 48-02-003)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 8119/08