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SAN JOAQUIM COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MAVTERFILE RECORD INFORMATION FORM—e SHADED SECTIONS FOR EHD USE ONLY OWNER ID# ,/t / OOO �7 �'w CASE# V OWNER FILE COMPLETE THE FOLLOWING BUSINESS OWN ER INFORMATION: CHECK IF OWNER CURRENTLY ON FILE WITH EH BUSINESS PHONE: OWNER'S NAME ^ �Tq' ��3�• / First MI Last BUSINESS NAME(If different from Owner Name) SOc Sec or Tax ID# OWNER'S HOME ADDRESS CITY STATE ZIP OWNER'S MAILING ADDRESS (if d' rent from Owner's Ad ea) Attention or Care of 1351 r�5 • MAILING ADDRESS CITY IWC) STATE zip TYPE OF OWNERSHIP: CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY OTHER❑ FACILITY FILE FACILITY ID#: CO-OWNER ID#: ACCOUNT ID#: COMPLETE THE FOLLOWING BUSINESS FACILITY INFORMATION: ND 6Ei2 Is this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES NO ❑ Mme......--, IS this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ NO 1Z BuslNEsslFACILiTY NAME(This will bethea S/NESSAI MEonthe EA THPER IT) Le) b Gr � bv� V� FACILITY ADDRESS(if FACILITY is a MOBILE FOOD UNITor FooD VEHICLE use the COMMISSARY ADDRESS) BUSINESS PHONE 55 F Na2Ne bi Suite# CITY(if FAciurnhI�s a MOBILE FOOD UNIror FOOD VEHICLE use the ComMissARYOW STA ZIP S-2 G �'J I BOARD OF SUPERVISOR DISTRICT Ov LOCATION CODE 0-2— KEY1 KEY2 MAILING ADDRESS for Health PerRllt(If DIFFERENTfmm Facility Address) Attention or Care Of MAILING ADDRESS CITY STATE ZIP SIC CODE: APN#: 06 N 107, COMMENT: ACCOUNTADDRESS for fees and charges: OWNER 5r 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 WIII 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 Regulations. APPLICANT'S NAME: SIGNATURE: Please Print TITLE: DATE DRIVER'S LICENSE# PHOTOCOPY REQUIRED Approved By 1 I Date IS IZ-71 1Y 11 Accounting Office Processing Completed By Data A PROGRAM{EHD 48-02-034 Pink)or WATER SYSTEM(EHD 46-02-003)form must be completed for each EHD regulated operation at is LOCATION except UST Program(Use SWRCB forms) EHD 48-02-035 Masterfile Record-Green 8/19/08