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SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM SHADED SECTIONS FDREHD USE ONLY II OWNER IDIII I II CASE# OWNER FILE COMPLETETHEFOLLOWING BUSINESS OWNER /NFORMA770N rucrrrix nwNFR r,rnncur, BUSINESS OWNER'S NAME BUSINESs(FACILITY NAME (This will be the BUSINESS NAfEon the HEALTH PERMIT) FACILITY ADDRESS (If FAD2/rYls a MOH/LE FOOD UNITOr FOOD VEHICLEuse the COMMISSARY ADDRESS) PHONE: O L� / 7 � < pp 74 / p �Z T!, First MI Last BUSINESS NAME (If different from Owner Name) OWNER'S HOME ADDRESS 2 CITY f �. (C ON $ T ZIP 7 S Z,o,_ OWNER'S MAILING ADDRESS (If different from 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 jJ FACILITY FILE FACILITY ID M. ;1Z__ IC 7a-.& >Zl7 CO-OWNER ID #: ACCOUNT ID #: COMPLETE THEFOLLOW/NG BUSINESS FACILITY /NFORMAT/ON: 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 ❑ BUSINESs(FACILITY NAME (This will be the BUSINESS NAfEon the HEALTH PERMIT) FACILITY ADDRESS (If FAD2/rYls a MOH/LE FOOD UNITOr FOOD VEHICLEuse the COMMISSARY ADDRESS) Suite # BUSINESS PHONE CITY (If FAQOrYIs a MOBILEFOOD UNITor FOOD VEHICLE use the COMMISSARYCITY) STATE ZIP BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 MAILING ADDRESS for Health Permit(If DIFFERENTfrom FacifityAddmss) Attention or Care Of MAILING ADDRESS CITY SIC CODE: APN #: COMMENT: STATE ZIP 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 ACCOUNT ADDRESS for this site. 1 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: c -Y /",, <�? /P`/'Id ry SIGNATUR 1/,P1 as Print' TITLE- DATE DRIVER'S LICENSE # - PHOTOCOPY REQUIRED Appl—d By Date Accounting Office Prcoaaeing Completed By Date 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) EHD 48-02-035 Masted le Record -Green 8119108