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SAN JOAQUIN COUNTY,,ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM r� CASE# SHADE/SECTIDNS FOR EHD USE ONLY OWNER ID# ftiD,9-; 'D ff a OWNER FILE COMPLETETHEFOLLOW/NG BUSINESS OWNER INFORMATION: CHECK IF OWNER CURRENTLfONFILE wiTHEHD❑ BUSINESS PHONE: OWNER'S NAME Z�4 ?,70 -7400 First M, Last I BUSINESS NAME(If different from Owner Name) Soo Sec orTax ID# s a� L OWNER'S HOME ADDRESS CITY t STATE ZIP _wr OWNER'S MAILING ADDRESS (If ditferentfromOwner's Address) Attention or Care of Z - /S 4' M O(4 o1 it.i^ 1 MAILING ADDRESS CITY T r C7" L STATE ZIP 7 7 TYPE OF OWNERSHIP: CORPORATION INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY OTHER❑ FACILITY FILE FACILITY ID#: FfCbt7 37 CO-OWNER ID#: I ACCOUNT ID#'",0P q3-j( COMPLETE THEFOLLOWING BUSINESS FACILITY INFORMATION; Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES ❑ NO ❑ 11caw ar.arut'] Is this an ExtSTtNG Business LOCATION but a NEw TYPE of regulated Business? YES ❑ No ❑ BUSINESSIFACILITY NAME(T is w5be the BuswEss NAMEon the HEALTH PERMIT) e ., FACILITY ADDRESS(If FACILrrYis a MOSILEFcVc UNtror FOOD VE1410LEllse the COMMISSARY ADDRESS) BUSINESS PHONE 0 G/b+4 e-- AV e_. Suite# CITY(If Fac&rrYls a MOBILE FOOD UNIT Or FOOD VEHrcLE use the COMMISSARY CI TYI STATE I zip SSG I(_' 4-C:"' 1 c A gsz 03 BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY 1 KEY2 MAILING ADDRESS fol Health PermIt(If DIFFERENTfrom Facility Address) Attention orCare Of MAILING ADDRESS CITY STATE zip SIC CODE: APN#: COMMENT: ACCOUNTADORES$for fees and charges: OWNER ❑ FACIUTYIBUSINESS ❑ BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and acknowledge that all PERMIT FEES,PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this Operation will be billed t0 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 Re ulations. APPLICANT'S NAME: SIGNATURE: Please Print TITLE; DATE DRIVER'S LICENSE# j PHOTOCOPY REQUIRED Approved By Date Accounting Office Processing Completed By I 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 8119108