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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM S/IADED SECMWS R7REHD USE DNLYOWNER ID# 0D02f113 CASE# OWNER FILE COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION: CHECKIF OWNER CURRENTLYON NLEWRH EHD rBUSINE S NAME PHONE F,, MI Last NAME(a rflterent Lwn(Tuner Name) Sac Sec or TaxID# T HOME ADDF '� 5 T2 16 LV42 STATE ZIP OWNER MAILING ADDRESS(M dtletenl can Owner gddress) 5Aftention or Care of MAILING ADDRESS CITY STATE ZIP TYPE OF OWNERSHIP: CORPORATION❑ INDMDUAL❑ PARTNERSHIP❑ LOCAL AGENC COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ FACILITY FILE FACILITY ID M CO-OWNER ID#: ACCOUNT ID#: , 3 COMPLETE THE FOLLOWING BUSINESS FACILITY INFORMATION: IS this a NEW Business LOCATION Of VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES NO ❑ Is this an E)OSTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ Named BUSINESS)FACILITY NAME(TMs Mir BUSINESSNAMEo HEALTH PERMITI T � � FACILITYA D ESS(IfFAaulY isalloaILE oUNITor F000U ,C�.E use the CowlssARY AOcnEss BUSINESS PHONE V 7 m rl // S 7 # CITY(if p pre;a MmLe F000 Uwr or FooD YEwo use the COMEaS49fiYGO 7JP -3/ 41 BOARD O/SUPERVISOR DISTRICT LOCATION CODE KEV1 KEY2 / MAIUNG ADDRESS for Health Permll(Ir DIFFERENTfram Fad/ib Add ass) Atlemion or Care Of MAILING ADDRESS CITY STATE ZIP SIC CODE: APN#: COMMENT: ACCOLINTAr1ORESSfor fees and charges: OWNER ❑ FACILITY/BUSINESS ❑ 1, the undersigned Applicant, certify that 1 am the Owner, Operator, or Authorized Agent of this Business,and I acknowledge that all PERMIT FEET,PENAL77E8,ENFORaWEA'T CHARCE.Y and/or HOURLY CHARCFs associated with this operation will be billed to me at the address identified above as the ACCOUNTAnDRFsc 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 JOAQUI N COUNTY Ordinance Codes and/or Standards and STATE and/or FEDERAL 1 aws and Regulations. APPLICANT NAME: SIGNATURE: Please Pant TITLE: DATE DRIVER'S LICENSE III Approved By Date Accounting Office Processing Completed By Date A PROGRAM(EHD 48-02-034 Pink)or WATER SYSTEM(EHD 46-02-003)forth must be completed for each EHD regulated operation at this LOCAT ON except UST Program(Use SWRCS forms) EHD 48-02-035 Masterfile Record-Green 10/9/2003