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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />SHADED SEC77ONS FOR EHD USE ONLY II OWNER ID # <br />00,90.2i4,7/ <br />OWNER FILE <br />CASE # <br />COMPLETETHEFOLLOWINGBUSINESS O INFORMATION.' <br />CHECK IF OWNER CURRENTLYONF EW/THEHD <br />/WNER <br />BUSINESS ��� /j `GZ� <br />a <br />OWNER NAME First MI <br />Last <br />BUSINESS NAME (If different from Owner Name) <br />Soc Sec orTax ID # <br />4�ormAdDnnns <br />FACILITY ADDRESS (HFACILIrris aMOBILEFOOD UHiror Food VEHICLEUSe the J <br />-_7s -ad <br />OWNER HOME ADDRESS <br />0y 2 6_7 D�D r CD <br />CITY <br />STATE <br />ZIP <br />OWNER MAILING ADDRESS (If diA'erent #w7er Add �) <br />CITY (If FAGLITYIS a MOBILE FOOD UNIT or FOOD VEHICLE USC the rOMMlccdaY Ci7Y) <br />Attention orCare of <br />MAILING ADDRESS CITY t ^ G, <br />ZIP <br />c <br />Zip <br />TYPE OF OWNERSHIP: <br />CORPORATION INDIVIDUACV1 PARTNERSHIP ❑ LOCAL AGENCY ❑ COUNTY AGENCY ❑ STATE AGENCY ❑ FED AGENCY ❑ OTHER ❑ <br />FACILITY FILE <br />FACILITY ID #: r l t U U d� 3 CO-OWNER ID #: ACCOUNT ID #: Q q 3 <br />COMPLETETHEFOLLOW/NG BUSINESS FACILITY INFORMATION' <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 a NEW TYPE of regulated Business? <br />Y NO <br />BUSINESS/FACILITY NAME (This w' I be the BUSINESS IrMEon ft HEALT PERMIT) <br />FACILITY ADDRESS (HFACILIrris aMOBILEFOOD UHiror Food VEHICLEUSe the J <br />-_7s -ad <br />BUSINESS PHONE <br />0y 2 6_7 D�D r CD <br />S`r, <br />SU,li@ # <br />CITY (If FAGLITYIS a MOBILE FOOD UNIT or FOOD VEHICLE USC the rOMMlccdaY Ci7Y) <br />ST/3Tz� <br />ZIP <br />c <br />C + <br />52b <br />BOARD OF SUPERVISOR DISTRICT / <br />LOCATION CODE / <br />KEY1 <br />KEY2 <br />MAILING ADDRESS for Health Perm t(lf D/FFERENTfrom Facil/tyAddress) <br />PCS 1301X3-7-7 <br />Attention orrare Of <br />MAILING ADDRESS CITY � cC � I v ' ( <br />vAPN <br />STAT f� <br />1 I <br />ZIP <br />SIC CooE: <br />#: <br />COMMENT: <br />LiCC0UMTdn]0REESSfOrfees and charges: OWNER ❑ <br />FACILITY/BUSINESS <br />BILLING AND COMPL►ANCE ACKNOWLF.DGMEw: I, the undersigned Applicant, certify that I am the Owner, Operator, or Authorized Agent of this <br />Business, and I acknowledge that all PERAHT FEES, PENALTmv, ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation will be <br />billed to me at the address identified above as the ACCnUNTADDREss for this site. I also certify that all information provided on this application is true <br />and correct; and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or <br />Please Print <br />TITLE: DATE DRIVER'S LICENSE # <br />Approved By� 2%I Date II Accounting Crfiice Processing Completed By Ll 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 I OrATION <br />except UST Program (Use SWRCB forms) <br />EHD 48-02-035 Masterfile Record -Green <br />10/9/2003 <br />