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SAN.JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MAa+ERFILE RECORD INFORMATION FORM SHADED SECTIONS FOR EHD USE ONLY OWNER ID# U 1A I /` -;)O G6 0 CABE# OWNER FILE / v COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION: CHECK IF OWNER CURRENTLY ON FILE WITH EHD BUSINESS MI Last WPHONE: /�,j OWNER'S NAME (&o-Z 20cf -02 D(, b First BUSINESS NAME(If different from Owner Name) SOC Sec or Tax ID# VA er f C a d, I w e VL OWNER'S HOME ADDRESS r x 3 0 CITY 42t-� + S iZ ZIP; D e n EMAILING'AMDDRE'SS RAILNG ADDRESS (if different from Owner's Address) Attention or Care of �J L CITY STATE ZIP TYPE OF OWNERSHIP: CORPORATION K INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATEAGENCY❑ FED AGENCY OTHER❑ FACILITY FILE FACILITY ID#: p(,1 CO-OWNERID#: ACCOUNTIID#: 7 COMPLETE THE FOLLOWING BUSINESS FACILITY INFORMATION: Ea-S V b 0(,0 ,I J Is this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES NO ❑ Is this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ NO BUSINESS/FACILITY NAME(This will be the BUSINESS NAMEon the HEALTH PERMIT) M2rtLAr.l _rot" wer CorNer _ FACILITY ADDRESS(If FACILITY IS a MOBILE FOOD UNITor FOOD VEHICLE use the COMMISSARY ADDRESS) BUSINESS PHONE 13�( I S S Looe- T-tee. Rh Suite �2)2�1-0280 CITY(If FACILRYIs a MOBILE FOOD UNROr FOOD VEHICLE use the COMMISSARY CRY) STA ZIP BOARD OF SUPERVISOR DISTRICTi1>1 LOCATION CODE `jf KEY1 KEY2 MAILING ADDRESS for Health Permlt(If DIFFERENTfrom Facility Address) Attention or Care Of MAILING ADDRESS CITY STATE ZIP SIC Co. L g APN P 2 D D So o COMMENT: ACCOUNTADDRESS for fees and charges: OWNER FACILITY/BUSINESS ❑ BILLING AND COMPLIANCE ACKNOWLEDGMENT: [,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# '''nnn PHOTOCOPY REQUIRED Approved By 1 l y/ Dete '12 17S ' 11 Accounting Office Proceeaing Completed By Date 11 ?h4 11 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 except UST Program(Use SWRCB forms) EHD 48-02-035 Masterfile Record-Green 8/19/08