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SAN JOAOCOUNTY ENVIRONMENTAL HEALTH DWENT MASTERFILE RECORD INFORMATION FORM SHADED SECTIONS FOR EHD USE ONLY OWNER ID# hf_'�oO 1 CASE# (� OWNER FILE COMPLETE THEFOLLOwING BUSINESS OWNER INFORMATION: CHECK IF OWNER CURRENT[YONFILE WITH EHD❑ BUSINESS PHONE: (� OWNER'S NAME (4 9 7 — 76UD First MI Last BUSINESS NAME(If different from Owner Name) Soo Seo orTax ID# OWNER'S HOME ADDRESS CITY 5 a- ` f 1 — - S zip O WNER'S MAILING ADDRESS(If differentfrom Owner's Address) Attention orCaro of MAILING ADDRESS CITY STATE ZIP TYPE OF OWNERSHIP: CORPORATION El INDIVIDUAL[:1 PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY[:1 STATE AGENCY[_1 FED AGENCY❑ OTHER❑ FACILITY FILE FACILITY ID#: CO-OWNER ID#: ACCOUNT ID#: COMPLETE THEFOLLOw/NG BUSINESS FACILITY INFORMATION: C I: l lJ IS this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES NO ❑ Is this an EXISTING Business LOCATION buts NIw TYPE of regulated Business? YES ❑ No BUSINESS FACILITY NA IT willb the BuswESSNon the HEALTH PE MIT) � '. L�i� t �qw �'ielb Dei DrA� e �� ibN FACILITY ADDRESS(tfFAc2aYis a Mou LEFOODUNror FWD VEHICLEuse the COMMISSARY ADDRESS) BUSINSSPHONE NS Suite# CITY(if FAaurYlsa M1oe'aeF//ooc�Ur//rzor F000 VEHICLEuselhe COMMISSMYCIYY) STAyb, ZIP BOARD OF SUPERVISOR DISTRICT O( KEY1 KEY2 MAILING ADORES for He III!Per Mit f DIFFERENT rom Fa h Ad ,s,) Attention rCam OF (�-f" E _ C(jPk RIMI S � F f( i s1S1ernJ b IjS P-0 -7 MAILING ADDRESS CIT�- \ �CPr\ G IS v STAT ()^ ZIP /� `-1J f �6 SIC CODE: 1`+ APN#:O7 060 ql�lf COMMENT: ACCOUNTADDRESS for fees and charges: OWNER FACILITY/BUSINESS 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: P/ease Print TITLE: DATE (PHOTDRIVER'S LICE PHOTOCOPY REQUIRED) Approved By V Dale (� f6 I Accounting Office Processing Completed By Dale 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 SW RCB forms) EHD 48-02-035 Masterfile Record-Green 11127/07