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SAN JOAQUI"t COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MAvrERFILE RECORD INFORMATION FORM— SHADED SECTIONS FOR EHD USE ONLY OWNER ID# ObT 6US CASE# OWNER FILE l COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION: CHECK IF OWNER CURRENTLY ON FILE WITH EHD BUSINESS PHONE: OWNER'S NAME First MI Last BUSINESS NAME(If different from Owner Name) SOC See or Tax ID# OWNER'S HOME ADDRESS CITY STATE ZIP OWNER'S MAILING ADDRESS (U different from Owner's Address) Attention or Care of 2 � N �� p� , MAILING ADDRESS CITY TYPE OF OWNERSHIP: CORPORATION E3 INDIVIDUAL El PARTNERSHIP E] LOCALAGENCY)Ff COUNTYAGENCY❑ STATE AGENCY FED AGENCY OTHER❑ FACILITY FILE FACILITY ID#: IX a CO-OWNER ID#: n ACCOUNTID#: COMPLETE THE FOLLOWING BUSINESS FACILITY INFORMATION: 2 O [ish IS a NEW BUSIneSS LOCATION Or VEHICLE not preVIOUSIy regulated by the ENVIRONMENTAL HEALTH YES L^L NONEXwhis an ExISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ NO BUSINESS/FLITY NAME(This will be the 6usmEss NAMEon to HEALTH PERMIT) FACILITY ADDRESS(IF FACILITY is a MOBILE FOOD UNIT or FOODVEHICLEUSS the COMMISSARY ADDRESS) BUSINESS PHONE -36-) l a v4N o Suite# Zo°i R S- z C CITY(IfFACIUTYIs OBILEFOOD NR FOOD VEHICLE use the COMMISSARY Ow STAT ZIP v� i�.�-u� ��l C4 S- 12 BOARD OF SUPERVISOR DISTRICT OD Z 1 LOCATION CODE O 1 KEY1 KEY2 MAILING ADDRESS for Health Perlrtlt(If DIFFERENTfrom Facility Address) Attention or Care Of MAILING ADDRESS CITY �-r STATE ZIP SIC CODE:W / APN#: I L Z v S6 � COMMENT: - r V E A.CCOUNTADDRESS for fees and charges: OWNER FACILITY/BUSINESS ❑ BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,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# """///111 PHOTOCOPY REQUIRED Approved By r IYZ Data 1 'L � 13 11 Accounting Moe Processing Completed By Data A PROGRAM(EHD 48-02-034 Pink)or WATER SYSTEM 1{EHD 46-02-0031 form must be completed for each EHD regulated operation 4t this L CATION except UST Program(Use SWRCB forms) EHD 48-02-035 Masterfile Record-Green 8119108