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r SHADED SECTIONS FOR EHD 113E ONLY SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM OWNER ID# I 01000.2-3..�?-ej OWNER FILE COMPLETE THEFOLLOW/NG BUSINESS OWNER INFORMATION: CASE # CHECK IF OWNER CURRENT( YON FII F wrrm FHnI 1 BUSINESS OWNER'S NAME NO ❑ BUSINS/FACILITY1NAME (Th' will a the B Ess NI the HEALTH PERMIT) Isciu ' PHONE: _QLJ UU __ II First I MI Last BUSINESS NAMi(If diRerentfro Owne ama) SOC SBC OrTax ID # OWNER'S HOME ADDRESS U LOCATION CODE CITY KEY2 SIM I ziP?140 OWNER 'SMAILINGAD RESS(Ifdifferent/rem 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 FACILITY ID #' 8 f CO-OWNER ID #: ACCOUNT ID #: COMPLETE THEFOLLOW/NG BUSINESS FACILITY INFORMATION.' Is this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES Is this an ExISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No NO ❑ BUSINS/FACILITY1NAME (Th' will a the B Ess NI the HEALTH PERMIT) Isciu FACILITY ADDRESS (If FAD¢Rr a MosILEFooDUNITor FOODVHICLE Se the COMMISSARY ADDRESS) �o9CN {�ua%n SD e# BUSINESS ZIP PHONE /D 615 NO CI (If FACILITY 15 a MOBILE FOOD UNRor FOOD VEHICLE Use the COMMISSARY CITY) L.�3Lii STATE I CA BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 MAILING ADDRESS for Health Parmit(If D/FFERENTfrom FaciiityAddress) Attention orCare Of MAILING ADDRESS CITY STATE ZIP SIC CODE: AP M. COMMENT: I ACCOUNTAM90s for fees and charges: OWNER ❑ FACILITY/BUSINESS BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1, 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 t0 me at the 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 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 Reaulations. APPLICANT'S Please Print TITLE: DATE 11 Approved By I Date II Accounting Office Proceaeing Completed By I /Z I Oct. / / , _ I _ rj 11 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 fortes) EHD 48-02-035 Masterfile Record -Green 8119/08