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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM SHADED SECTIONS FOR EHD USE ONLY OWNERID# aooaa'am CASE OWNER FILE COMPLETE THE FOLLOW/NG BUSINESS OWNER/NFORMAT/ON: CHECK tF OWNER CURRENTLY ON FILE wiTH EHD❑ BUSINESS PHONE: OWNER'S NAME First I oil Last BUSINESS NAME(If different from Owner Name) SOC Sec orTax ID# OWNER'S HOME ADDRESS CITY STATE zip ONER'S MAILING ADDRESS (If d/fferent from Owner's Address) Attention or Care of loZ MAILING ADDRESS CITY I /��1 zip qq / I TYPE OF OWNERSHIP: CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY OTHER❑ FACILITY FILE FACILITYID#: C)01 1 J CO-OWNERID#: ACCOUNTID#: jlAJQ,pb O �� COMPLETE THE FOLLOW/NG BUSINESS FACILITY INFORMATION: Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES NO ❑ nco.o...�.,ro IS this an ExISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ NO ❑ BUSIN SIFACIUTY NAME(This will be the BUSINESSNAMEOn the HEALTH PERMIT) Q FACILITY ADDR (IfFAC/uTris a MOBILEFOOO UNITOr Foo�jlCLEus the Commssa ADDRESS) BUSINESS PHONE 1 '1 ' - Suite# U — q`-t CI (If FA D1/ITYIS a MOBILE FOOD UNrror FooDVEHrcLEusethe COMMISSARY CITY) STATE ZIP La LAO BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEV1 KEV2 MAILIN"ADDRESS 3®RESHealth Permtt(If DIFFERENTfrom Facility Address) Attention or Care Of MAILINI STATEO;q ZIP SIC CODE: APN#: COMMENT: ACCOUNTADORESS 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 WIII be billed tome at the address identified above as the ACCOUNT ADDRESS 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 Date AccountlnB Office Processing Completed 0y ome A PROGRAM{EHD 48-02-034 Pink)or WATER SYSTEM{EHD 46-02-0031 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 8119/08