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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM SHADED SECTIONS FOR EHD USE ONLY OWNER ID # %) t l/�f / CASE # �J OWNERFILE COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION: CHECK IF OWNER CURRENTLY ON FILE wITH E H DY BUSINESSPHONE: OWNER'S NAME In Cath�J ❑ No ❑ /.I_ y I n „ 3OG) W lY 1 First MI Last BUSINESS NAME (Ifdifferent from Owner Na e) - Soc Sec or Tax ID # OWNER'S HOME ADDRESS CITY 5 \ (JI 1 Lam.^Sol t Number Direction Street Name Street zip 5 Z, J OWNER'S MAILING ADDRESS (I differentif m Owner's Address) Att tion or car of 'M yl cco MAILING ADDRESS CITY ( ZIP 1 Z ) TYPE OF OWNERSHIP: CORPORATION ❑ INDIVIDUAL ❑ PARTNERSHIP ❑ LOCAL AGENCY ❑ COUNTY AGENCY STATE AGENCY ❑ FED AGENCY OTHER ❑ FACILITY FILE p FACILITY ID #: F - o-0.2 33 5 CO-OWNER ID #: ACCOUNT ID #: /` J COMPLETE THE FOLLOWING 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 ❑ BU INESSIACI T NAM�(This will be the BUSINESS NAME o the H ALTH PgMIT)I - j t,� I c (21, FACILITY ADDRESS (If FACILITY is a MOBILE F000 UNIT or F000 VEHICLE u the CoMMiss Y ADDRES BUSINESS PHONE t Number Direction Street Name Street T- Suite # rIlfCILITY IS a MOBILE FOOD UNIT or FOOD VEHICLE use the COMMISSARY CITY) STATE ZIP BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 MAILING ADDRESS for Health Permit(If DIFFERENTfrom Facility Address) Attention or Care Of MAILING ADDRESS CITYI STATE ZIP SIC CODE: I APN #: COMMENT: ACCOUNT ADDRESS 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 ACCOUNTADDREss 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 :EDERAL Laws and Reaulations APPLICANT'S NAME: ❑IQ+� ' l'(,�j4" SIGNATURE: �V Please Print DRIVER'S LICENSE # TITLE. DATE I J (PHOTOCOPY REQUIRED) 11 Approved By I Date 11 Accounting Office Processing Completed By , ///) I Date 1-�/j ,—/ i 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 forms) EHD 48-02-035 Masterfile Record -Green 8/19/08