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SAN JOAQ' ' COUNTY ENVIRONMENTAL HEALTH Dr \RTMENT WSTERFILE RECORD INFORMATION FORM` SHADED SECTIONS FOR EHD USE ONLY OWNER ID# � O �n .r�C CASE# OWNER FILE OMPLETE THE FOLLOWING BUSINESSOffliNFORMA7TON; CHECK IF OWN ER CURRENTz r ON FTtE WITH EH D❑ BUSINESS Pc ONE' S Z rY, r4 o-Q OWNER'S NAME Fvst MI Last 7 L BUSINESS NAME(If d!/rermtAtm owner Name) SOC Set orTax ID# r✓ sS N G OWNER'S HOME ADDRESS pLDS I ✓' CITY L/ G dKi STATE ZIP qZ -S/ OWNER'S MAILING ADDRESS (If d/HErent from Owner's Address) Attention orCare of MAILING ADDRESS CITY STATE ZIP TYPE OF OWNERSHIP: CORPORATION El INDIVIDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ FACILITY FILE FACILITY ID#: CO-OWNER ID M ACCOUNT ID#: 7HFFoLLowi1yGBUSINESS EAC1LrTY INFORMATION., Is this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT- YES ❑ NO ❑ Is this an ExISIING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ❑ BUSINESSIFACILITY NAME(Thi will t Ess, on the HEALTH PERMIT) . _11-Z FACILITY ADDRESS(If FA[ is a AMFaaoywor FCOD I EHT, a se the ) SINE PHONE 7 Z /�,e/✓'r i� suite D —4 Z r' 5 7,7 CITY(If FADILTTYIS a MOBILEFOOD UNrr oVEHtcLE use ef`nNNisss rflTv) STATE zIP9,3o � BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 MAILING ADDRESS for HeaIUT Permit(ir D/FFERENTfrom Faciltty Address) Attention aware Of MAILING ADDRESS CITY STATE ZIP SIC CODE: APN At: COMMENT: eri'ntrArT•AnnRESS for fees and charges: OWNER ❑ FACILITY/BUSINESS ❑ Bai INT.AND CoMPI IANCE Arurinwi Pnr.MFNr; 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 ADORES S 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 Re ulations. APPLICANT'S AME' SIGNATUREE Please Print TITLE: DATE DRIVER'S LICENSE# Approved BY a Date / 3 Accounting Omni Processing Completed By Data t, !r�'/ A PROGRAM (EHD 48-02-034 Pink} or WATER SYSTEM (EHD 46-02-003) form must be completed for eacb EHD regulated operation at this I nrATrnN except UST Program(Use SWRCB forms) EHD 48-02-035 Masterfile Record Green 8/19/08