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SHADED SECTIONS FOR EHD USE ONLY SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM OWNER FILE COMPLETE THE FOLLOW/NG BUSINESS OWNER INFORMAT/ON: CHECK iF OWNER CURRENTLYON FILE wiTH EHD❑ BUSINESS OWNER'S NAME God Atww>a' S;,ep( OWNER ID 01.90/);231D n � CASE# Last OWNER FILE COMPLETE THE FOLLOW/NG BUSINESS OWNER INFORMAT/ON: CHECK iF OWNER CURRENTLYON FILE wiTH EHD❑ BUSINESS OWNER'S NAME God Atww>a' S;,ep( PHONE: First MI Last BUSINESS NAME (If different from Owner Name) y OWNER'S HOME ADDRESS CITY SToc--TOY TE ZIP QS20f3 OWNER'S MAILING ADDRESS (If differentfrom Owner's Address) Attention or Care of MAILING ADDRESS CITY t Fj C 1:5C4 _.! A"& S -Ir JJ -,4 STATE ZIP q5 zos TYPE OF CORPORATION LL INDIVIDUAL I—] PARTNERSHIP El LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY ❑ FED AGENCY OTHER LJ FACILITY FILE FACILITY ID #: I%kVp 2ZLf ,7 2-- CO-OWNER ID #: ACCOUNT ID #: 00'17�% / COMPLETE THEFOLLOw/NG BUSINESS FACILITY INFORMATION: Is this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES NO ❑ Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No nT� BUSINESSIFACILITY NAME (This will be the BuswEss NAMEOn the HEALTH PERMIT) 6vll i'O eA l.! v�r Q Il0P0 .n ,' M 11 G °f I / FACILITY ADDRESS (N FACIL/Tris a MOBI LEt�FOoD UNnerr FOOD ✓EHICLEuee the COMMISSARY ADDRESS) BUSINESS PHONE r -t � 4 �j 95 - 3550 _ A r `FO Suite # L" I CITY (If FAca-trYIs a MOBILE FOOD UNrror FOOD VEHICLE use the COMMIssARY Cart) STATE ZIP CAgs2o3 BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEV1 KEV2 MAILING ADDRESS %r Health Permlt(If DIFFERENTfrom FaciiifyAddmss) Attention or Care Of 16 10 Ff c l6( 4tr STe :# q svtad n x1 91 MAILING ADDRESS CITY S IG dd 5�toc t`�an ca 95203 STATE & ZIP q5 Zvi SIC CODE: APN #: COMMENT: ACCOUNTADORESS 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 ACCOUNT ADDRESS for this site. I also certify that all information provided on this application is true.a • and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or 5talfdards and STATE d/or (co los Please Print TITLE: DATE 1IApproved By Dere II AccounOng Office Processing Completed By / /L I Dete 2I /' / / 19 II 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) /- EHD48-02-035 W -f�r �ry _ g7j6rO /q „vy 441 - ^ Masterfile Record -Green 8/19/08 (.t (fit ejo ' ( CT l/ }✓-/- 7 eT1 l-vf • 1