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SAN JO,a.JIN COUNTY ENVIRONMENTAL HEALTH [�ARTMENT MASTERFILE RECORD INFORMATION FORM SHADED SECTIONS FOR EHD USE ONLY OWNER ID# 9'6 7 CASE# OWNER FILE COMPLETE THEFOLLOwING BUSINESS OWNER AfFORMAT/ON: CHECK/F OWNER CuRRENRY oNFxE wErHEHD❑ BUSINESS PHONE: OWNER'S NAME (_l1l First MI Last Zn!A lLaL BUSIN NAME(If dif if, ner Nam ) SOC Seo or Tax ID# OWNER'S HOME AD SS CITY STATE ZIP O NER'S MAILINGAQDRES di9erent f, Owner's Add as) Atlentlon orcara of �� MAILING ADDRESS CITY T E ZIP TYPEOFOWNERSHIP: CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP El LOCAL AGENCY El COUNTY AGENCY STATE AGENCY El FEDAGENCY❑ OTHER❑ FACILITY FILE FACILITY ID#@ka.219 CO.OWNER ID#: ACCOUNT ID#: 3 COMPLETE THE FOLLOWING BUSNESS FACILITY INFORMATION: Is this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO ❑ Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ NO ❑ BUSINESS/FACILITY NAME(This will be the Buswn NAMEOn the HEALTH PERMIT) FACILITY ADDRESS(If FACILITTis a M0E2EFWD UNIrOr FOOD✓EHICLEuse the COMMISSARY ADDRESS I BUSINESS PHONE Suite# CITY(if FADluTns a MOBILE Food UNIT or FOOD VEHIDLE use the CoMMlssA yCllr) STATE ZIP BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 MAILING ADDRESS for Health Perm/t(If DIFFERENTfmm Facility Address) Attention or Care Of MAILING ADDRESS CITY STATE ZIP SIC CODE: APN#: Co__ ["_OO 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 ACCOUNT ADDRESS 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 Al PHOTOCOPY REQUIRED Approved ey Date Accounting Office Processing Completed By Date l A PROGRAM{EHD 48-02-034 Pink)or WATER SYSTEM{EHD 46-02-003)form must be completed for each EHD regulated operation t thiL CATION except UST Program(Use SWRCB forms) EHO 48-02-035 Masterfile Record-Green 11127/07