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SAN JOAQUTA' COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> M)MTERFILE RECORD INFORMATION FORNIr! <br /> SHADED SECTIONS FOR EHD USE ONLY OWNER ID# /)w boo Q /�b CASE# <br /> VV OWNER FILE (/ <br /> COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION: CHECK IF OWNER CURRENTLY ON FILE wfTH EH <br /> BUSINESS PHONE: [p /) <br /> OWNER'S NAME Z Z U — <br /> First MI Last <br /> BUSINESS NAME(If different from Owner Name) Soo Seo Or Tax ID# <br /> r` C.ArJ R QC <br /> OWNER'S HOME ADDRESS Pr '•U a 3� 0 l <br /> CITY [A v Q w } S TD zip 6 5`6 rg 2 <br /> OWNER'S MAILING ADDRESS (If different from Owner's Address) Attention or Care of L v <br /> MAILING ADDRESS CITY STATE zip <br /> TYPE OF OWNERSHIP: <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID#: CO-OWNER ID#: ACCOUNT ID#: <br /> COMPLETE THE FOLLOWING BUSINESS FACILITY INFORMATION: C c-(L� TE) IDLIDJrGOCI <br /> IS this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES NO ❑ <br /> nom,..er..�.,.•s <br /> Is this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ NO <br /> BUSINESS/ A^^ITY NAME(This will be the BOSINEses NAMEon th=HEALTH PER iIT) sI <br /> FACILITY ADDRESS(If FACILITY is a MOBILE FOOD UNITor F000 VEHICLE use the COMMISSARY ADORES ) BUSINESS PHONE <br /> Z Gl N ;C, OL-S Rn. 6v2) Zd -OZ " <br /> Hoist Ham Strppt T—aL— <br /> Su to# <br /> CITY(If FAciL is a MOBILE FOOD UNIT or FooD VEHICLE use the COMMISSARY CITYI STAT 7jpI.S�o <br /> AST <br /> BOARD OF SUPERVISOR DISTRICT00(.? LOCATION CODE KEY1 KEY2 <br /> MAILING ADDRESS for Health Perlfllt If DIFFERENTfrom Facili Atldress) Attention Or Care Of <br /> O <br /> MAILING ADDRESS CIN P D e N ( q �] STATE ZT S-0 O Ll <br /> SIC CODE: U ( APNm oQ SV U0/ /O COMMENT: rj L <br /> ACCOUNTADDRESS for fees and charges: OWNER ❑ FACILITY/BUSINESS <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,PENALnEs,ENFORCEMENT CHARGES and/Or HOURLY CHARGES associated with this Operation will be billed to me at the <br /> 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 <br /> all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or <br /> FEDERAL Laws and Regulations. <br /> APPLICANT'S NAME: SIGNATURE: <br /> Please Print <br /> TITLE: DATE DRIVER'S LICENSE# <br /> PHOTOCOPY REQUIRED <br /> Approved By 1 Date r'1 ,I I Awourbng Office Processing Completed By Date 1 <br /> A PROGRAM{EHD 48-02-034 Pink}or WATER SYSTEM(EHD 46-02-003)form must be completed for each EHD regulated operation 4t th s LOCATION <br /> except UST Program(Use SWRCB forms) <br /> EHD 48-02-035 Masterfile Record-Green <br /> 8119/08 <br />