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SAN .JOA N COUNTY ENVIRONMENTAL HEALTH ARTMENT SIASTERFILE RECORD INFORMATION F SHADED SECTIONS FOR EHD USE ONLY OWNER ID# >�(�iJ .� CASE# OWNER FILE COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION: CHECK IF OWNER CURRENTLY ON FILE wITH EHD❑ BUSINESS PHONE: OWNER'S NAME First M/ Last BUSINESS NAME(If different from Owner Name) See Sec or Tax ID# �~ I i4 OWNER'S HOME ADDRESS C3Z Y'c-t CITY STATE ZIP OWNER'S MAILIN ADDRESS (If different from Owner's Address) Attention or Care of MAILING ADDRESS CITY STATE ZIP TYPE OF OWNERSHIP: CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY FED AGENCY OTHER❑ FACILITY FILE FAcIUTYID#:� a ' CO-OWNERID#: I ACCOUNTID#: COMPLETE THE FOLLOWING BUSINESS FACILITY INFORMATION: 15 this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES 1 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) FACILITY ADDRESS(If FACILITY is a MOSILE FOOD UNtNtror Fco,VEHICLE use the COMMISSARY ADDRESS) BUSINESS PHONE K.-i (GS S L O K� Pa,' sa, `�<,SS /wycX G�" CA FIgy • cry, �BDite# �`J�I S33-Zaz CITY(IfFAaLlrrls a MOBILE FOOD UNITor FOOD VEHICLE use the COMMISSARY CITY) STATE ZIP BOARD OF SUPERVISOR DISTRICT j LOCATION CODE 9� KEY1 KEY2 ' MAILING ADDRESS for Health Permit(If DIFFERENTfrom Facility Address) Attention orCare Of MAILING ADDRESS CITY STATE ZIP SIC CODE: APN#: 110 r12 COMMENT: ACCOUNTADDRESS for fees and charges: OWNER FACIUTYIBUSINESS ❑ 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 AcCOUNTAODREss 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 Approvetl By Date Accounting Once Proceasing Completed By Do J 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) (//��t/r�� EHD 48-02-035 �✓( Masterfile Record-Green 8119/08