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SAN.JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> SHADED SECTIONS FOR EHD USE ONLY CWNER ID# ol. IOhI� CASE# <br /> OWNER FILE <br /> COMPLETE THEFOLLOW/NG BUSINESS OWNER tNFORMAT70N: CHECK/F OWNER CURRENTL YON FILE WITH EHD❑ <br /> MBUSINEssNAME(lf <br /> �� TPHONE:AME209 ,35Flrsl Ml Las( ,9 ME(If diRarent from Owner Name) oCSe orTaxID# <br /> Q Q HOME ADDRESS _ M^ L� Zip a �DILING ADDRESS (If di9erent from er'e Address) Attention orCere �/3�-RESS CITY 49 i t W-0 $TQ ZIP _ / <br /> TYPE OF OWNERSHIP: <br /> CORPORATION E] INDIVIDUALt PARTNERSHIP[] LOCAL AGENCY El COUNTY AGENCY❑ STATE AGENCY E] FED AGENCY OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID#: ptj Z3 CO-OWNER ID#: ACCOUNr ID#: L <br /> COMPLETE THEFOLLOW/NG BUSINESS FACILITY AfFORMAT/ON.- <br /> IS this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES NO ❑ <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ NO <br /> BUSINESS/FACILITY AME(This Will bp the Bus UNAMEon the HEALTH 77 <br /> L Q <br /> FACILITY ADDRESS(If FAC/LnYib a MOB/LEFOOD UNITOr FDOD VEH/CLEUSSI the COMMISSARY ADDRESS) BUSINESS PHONE <br /> �( S al <br /> &M 9ot�a�(o SD ek ) <br /> CITY(If FACILrrIS a MOBiLEFOOD UNnor FOOD VEN/cLEuse the CommissARY CITrI $TATE Zip <br /> FG D-) GG- <br /> 10 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEYt KEY2 <br /> MAI LLIING ADDRESS for Health PermItjlf D FFFEEReryl"fro m Facility Address) Attention arcane Of <br /> �J ■ C�Gl(( ✓I l V�q <br /> MAILING ADDRESS CITY G.. � $TATE ZIP <br /> SIC CODE: APN#: COMMENT: <br /> ACCOUNTADDRESS for fees and charges: OWNER ❑ FACILITY/BUSINESS <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Owner, Operator,or Authori 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 /> APPLICANTS NAME: SIGNATURE: <br /> Please Print <br /> TITLE: a DATE —2 DRIVER'S LI PHOTOCOPIY REQUIRED 25 <br /> /^ <br /> Wo Oele AeeoulNng Mes Processing Completed By oeb 3 <br /> 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 <br /> except UST Program(Use SWRCB forma) <br /> EHD 48-02-035 Masterfile Record-Green <br /> 8119/08 <br />