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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM -- <br /> SHADED SECTIONS FOREHD USE ONI Y OWNER ID# l%G✓ �f/aC.3� 7.� (� I <br /> OWNER FILE <br /> COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION: <br /> CHECK IF OWNER CURRENTLY ON FILE WITH END <br /> — <br /> [BNE <br /> S do.✓ALD L F/rfRPfZ PHONE: <br /> S NAME .._.__ __.._ _...- t // p r� <br /> Fat MI _._.._. Lnat �7 < Lr_ t!q <br /> NAME(If diftrantfrmOwner Name) a Boo orTax ID# <br /> �, 7'S HOME ADDRESS l 7 7 G ?ST.-J STAB ZIP fi 41,76 <br /> OWNER'S MAILING ADDRESS(S diderent <br /> ?Y0 E, T,4 —1'-11 t- f-T. <br /> MAILING ADDRESS CITY ("�N STAT E ZIP A j J 3 Z <br /> TYPL OE OWNERSHIP: l i9 _ .J <br /> CORPORATION[I INDIVIDUAL❑ PARTNERSHIP El LOCAL AGENCY[3 COUNTY AGENCY E] STATE AGENCY E) FEDAOENCY OTHER <br /> FACILITY FILE <br /> FACILITYID#_� b �.(.f- �L},. i.-.CO.OWNER ID#: ,.- ACCOUNT ID III: OD Lj {pLI <br /> COMPLETE THE FOLLOWING BUSINESS FACILITY INFORMATION: <br /> L181 NEW Buslne88 LGCpTIDN Cr VEHICLE not preWGUeIy regulated by th0 ENYIgDNMENTAL HEALTH YE$ ❑ NOE!'n Ex1i TING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ NO .SBIFADILITY NAMa(This walWlhe BuslNEsa NAMEOa the ++EALTH 'pS e- JT LG125 Sv7GCY ADDRESS(11FACILnY b 8 Mo E Food UNlror FOOD VENIG.EYNB the Cq ISSARr PPRES$) BUSINESS PHONE <br /> D /ASGa.4"C.P cos AVB. <br /> Suoe N <br /> CITY(if FACa"Is a MdetEFow UNRor FOOD VEMdLEuR,me COMMISSARY CI STATE ZIP <br /> /v'fLv fEc� c,, '7S-3 3 6 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> MAILING ADDRESS for Health Permll(If DIFFERENTROM FARDWYAddrees) Attention or Cars Of <br /> 11 1 r TA�"ie a2 i t <br /> MAILING ADDREss 190 <br /> CirY s � f <br /> STATE 6,,f MIS <br /> SIC CODE: APN N, COMMENT: <br /> AC000NTADDREW for fees and charges: OWNER [ FACILITYIBUSINESS <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT! I,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and <br /> I acknowledge that all PERMIT FEES,PENpLt1YfS,ENr PCEMENT CHARGES andlor HOURLY CHARGES a8SOClated with this operation will be billed to me at the <br /> address Identified above as We ACCOUNT ADDRESS for this site. I also certify that an Information provided vn this application Is true and correct;and that <br /> all regulated activities will be performed in accordance with all applicable S41N JOAQUIN COUNTY Ordinance Codes and/or Standards antl STATE and/or <br /> L Laws and Regulations, <br /> APPLICANT'S NAME: .I o-✓ T�i SIGNATURE' <br /> Please Print <br /> TITLE: 17x Awl .f � Z <br /> E '"Mo COPI SLICEREgNSE# Jig 3032 <br /> R OF �DM LS yr /7 1201,9 (pHOTOUIRED <br /> �I APPrewtl BY - Deli ApoounDne officePraoeNlnp OompHledey -71, <br /> 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 LQ0gTION <br /> except UST Program(Use SWRCB forms) <br /> EHD 4e 02-035 <br /> 61119108 <br /> Meeterille Reoced.Grew <br />