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y SAN JOIN COUNTY ENVIRONMENTAL HEALTH ARTMENT MASTERFILE RECORD INFORMATION FORM SHADED SECTIONS FOR EHD US£ONLY OWNER I # /y CASE III. OWNER FILE COMPLETE THE FOLLOW/NG BUSINESS OW N ER/NFORMAT/OM. CHECK IF OWNER CURRENTLYON FILE WITH EHD❑ BUSINESS Last PHONE: OWNERS NAME Firsf MI BUSINESS NAME(If iferentiromOwner Name) Soo Sec orTax ID# OWNER'S HOME ADDRESS v57O -acv. VC— CIN n SATE ZIP O/ � � `a7 �C OWNER'SMAILING DDRESS(If differentirom Owner's Address) Attention arcane of MAILING ADDRESS CITY STATE ZIP TYPE OF OWNERSHIP: CORPORATIO<h INDIVIDUAL❑ PARTNERSHIP El LOCALAGENCY❑ COUNTY AGENCY E] STATE AGENCY 1-1 FED AGENCY El OTHER❑ FACILITY FILE FACILITY ID M-Ed0=1221CO.OWNER ID#: ACCOUNT COMPLETE THE FOLLOWING BUSINESS FACILITY/NFORMAT/ON: IS this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES No ❑ Is this an ExISTING Business LOCATION but NEW TYPE of regulated Business? YES ❑ No ❑ BUSINESS/FACILITY NAME(This will be the Bus/NEssi%( Eon the HEALTH PERMIT) FACILITY ADDRESS( AO/LIrYlI�ea MOB/LE FOOD UNITar FOOD VEHICLEuse the COMMISSARYADDRESSI BUSINESSPHONE Suite# CITY(If FAci=is a MO-ILEFOOD UNRor FOOD VEHICLE use the Co-MIssARY CmI STATE ZIP <S3 BOARD OF SUPERVISOR ISTRICT LOCATION CODE 7 J KEY1 KEY2 MAILING ADDRESS for Health Permtt(If D/FFERENTfram FaciiityAddres) Attention orCare Of �- MAILING ADDRESS CITY STATE oJQ / o7-1 SIC CODE: APN#: ( Gl' COMMENT: ACCOUNTADORESS forfees and charges: OWNER ❑ FACILITYIBUSINESS 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 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 DRIVER'S LICENSE# TITLE: DATE PHOTOCOPY REQUIRED Approved By Oat- Accounting Once 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 this OCATION except UST Program(Use SW RCB forms) Masterfile Record-Green EHD 48-02-035 11/27107