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SHADED SECTIONS FOR EHD USE ONL Y <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />OWNERID# �(NV� �' �J / l� CASE If <br />OWNER FILE <br />COMPLETE THEFOLLOW/NG BUSINESS OWNER INFORMATION.- CHECK IF OWNER CuRRENTLY oN FiLE wirH EHD❑ <br />BUSINESS <br />OWNER'S NAME <br />�� r`^ <br />CC(5 , <br />l/y `/ <br />QPHONE: q t <br />First+ <br />M/ <br />Last <br />BUSINEssNAMF IfditferentfremOwner Name) <br />SOC Sec orTax ID# <br />OWNER'S HOME ADDRESS 3'9(l AyV DE) S Vk_76 A <br />r <br />CITY SIN M 0u <br />E <br />ZIP <br />OWNER'S MAILING ADDRESS (if dirffre�n-tfromOwnees Address) <br />I e\'y/1i — <br />Attention orCars of <br />MAILING ADDRESS CITY <br />STATE <br />ZIP <br />TYPE OF OWNERSHIP: <br />CORPORATIO INDIVIDUAL EI PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY El STATE AGENCY❑ FED AGENCY [:1 OTHER Ll <br />FACILITY FILE <br />FACILITY IDM C f0v012L id(, CO.OWNER IDM ACCOUNTID#: 04? -780 <br />COMPLETE THEFOLLOw/NO BUSINESS FACILITY /NFORMAT/ON: <br />Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO <br />Is this an ExISTING Business LOCATION but NEW TYPE of regulated Business? YES El No <br />BUSINESS/FACILITY NAME (This will be the Rus/NEssNn on the HEALTH PERMIT) <br />l�iQ <br />FACILITY ADDRESS (HFAc2Imis as MOSILLEAnoe UMror FOOD VEHICLEuse the COMMISSARY ADDRESS) <br />6vb [..�j \\� J �• <br />Suite It <br />BUSINESS PHONE <br />q <br />N Y 9� 2- b b7 `} <br />CITY (if FAOUTYlssarya MOBILE Foo'O LIMIT or FOoo VEHIcu: use the COMMISSARY CITY) <br />✓ �Zni <br />STAT�� <br />ZIP <br />BOARD OF SUPERVISOR DISTRICT <br />LOCATION CODE <br />KEY1 <br />KEY2 <br />MAILING ADDRESS for Heatttf Permrt(If DIFFERENTfrom Facility Address) <br />Attention orCane Of <br />MAILING ADDRESS CITY <br />STATE <br />ZIP <br />SIC CODE: <br />APN #: <br />COMMEM: <br />ACCOUNTADDRESSforfeesand charges: OWNER ❑ <br />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 I <br />acknowledge that all PERMIT FEES, PENALTIES, ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this Operation will be billed t0 me at the <br />address identified above as the ACCOUNTADORESS for this site. I also certify that all information provided on this application is true and correct; and that all <br />regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or FEDERAL <br />Laws and Reculations. _ <br />TITLE: f D(PHOTOCOPY NSE# ATE ��(�'–C� 'SLICEEQUI <br />(PHOTEDI <br />Approved By I Date II Accounting OIFlee Processing Completed By r> I Date <br />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 <br />except UST Program (Use SWRCB forms) <br />EHD 48-02-035 Masterfile Record -Green <br />11127107 <br />