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SAN JOAr"9N COUNTY ENVIRONMENTAL HEALTH D�-ARTMENT .STERFILE RECORD INFORMATION FO._,r SHADED SECTIONS FOREHD USE ONLY OWNER ID# CASE# OWNER FILE COMPLETE THEFOLLOw/NG BUSINESS OWNER /NFORNAT/ON. CHECK 1F OWNER CuRRENrt rON FILE wirH EH D❑ BUSINESS PHONE: OWNER'S NAME , 1 Fvsl MI Las! BUSINESS NAME(If different from Owner Name) Soc Sec or-Tax ID# OWNER'S HOME ADDRESS CITY STATE zip OWNER'S MAILING ADDRESS (If different from Owner's Address) Attention orCare of MAILING ADDRESS CITY STATE zip TYPE OF OWNERSHIP: CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY STATE AGENCY❑ FED AGENCY OTHER❑ FACILITY FILE f, p FACILITY ID#:`.% 2Do223�(a CO-OWNER ID III: ACCOUNT IDM /�.BD� !JZ,I : COMPLETE THE FOLLOW/NG BUSINESS FACILITY INFORMATION: r1s INS a NEW BuSlness LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES NO........, 1 this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ NO ❑ SINESS/F�WLITY NAME(This will be he SUS/NESS oyAmEon the LTH PERMIT) 1 FACILITY ADDRESS(RF canris a MOBILEFbac UNlror FDpb VEHICLEuse the COMMISSARY ADDRESS) BUSINESS PHONE 21. 1 E �Ce sZ(V (o CITY(IfFACILPY Is a MOBILE FOOD UNIT or FOOD VEHICLE use the COMMISSARY Cm) ST TE zip —71 BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEPI KEY2 MAILING ADDRESS for Health Permft(If DIFFERENTfrom Facility Address) Atlerrdio or Caro MAILING ADDRESS CITY STATE zip SIC CODE: APN#: COMMENT: ACCOUNTADDRESS 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 Dale AccoanOng QAu Processing Completed By A PROGRAM(EHD 48-02-034 Pink)or WATER SYSTEM{EHD 46-02AM11%form must be completed for each EHD regulated operation at this LOCATIONI except UST Program(Use SWRCB forms) EHD 48-02-035 Masterfile Record-Green 8119/08