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SAN JOAOI-IIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 3TERFILE RECORD INFORMATION FO. I SHADEDSEC77ONSFORFHD USE ONLY LOWNER ID# Q O CASE# COMPLETETHEFOLLOWINGBUSINESS OWNER INFORMATIoNN,NER FILE CHECKlF OWNER CURRENTLYON FILE WITH EHD rj BUSINESS HONE OWNER NAME rj First MI Last ZO is BUSINESS NAME(If different from Owner Name) SOC Sec orTax ID# C'/ /r O c Ci 14 OWNER HOME ADDRESS /DD k1 G,'/V7_r CITY Nr/G STATE ZIP OWNER MAILING ADDRESS (ifdifferentfrom Owner Address) Attention o-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 M CO-OWNER ID#: ACCOUNT ID ; COMPLETE THEFOLLOWING 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 ❑ BUSINESSIFACILITY NAME(This will be the BUSINESS NAMEon the}ZEAL H PER IT) G r LU Z FACILITY ADDRESS(K FACILITrls a MOWLEFOOO UNITOr FOOD VEHtmEuse the CQMMIssARV AnnRFcc) BUSINESS PHONE /O 5.3 !� ��O Suite# CITY(If FACtuiYls a MOBILEFOOD UNITor FOOD VEHIcLE use the CammnsARv=) STATE- ZIP CA .f 3 BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 MAILING ADDRESS for Health Permit{if DIFFERENTfrom Facility A ddress) Attention orCare Of MAILING ADDRESS CITY STATE ZIP SIC CODE: APN#: COMMENT: for fees and charges: OWNER ❑ FACILITY/BUSINESS ❑ BILLING AND COMPLIANCE ACKNOWLF.DCMFNr: I, the undersigned Applicant, certify that L 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 ACCOUNTADDRFSS 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 Daws and Re ulations. APPLICANT NAME: SIGNATURE: Please print TITLE: DATE DRIVER'S LICENSE#(PHOTOCOPY REQUIRED) pr Approved By . I Date 2� Accounting Office Processing Completed By Date { O A PROGRAM{EHD 48-02-034 Pink)or WATER SYSTEM(EHD 46-02-003)form trust be completed for Each EHD regulated operation at thisOCATIO except UST Program(Use SWRCS forms) EHD 48-02-035 Masterfile Record-Green 1019!2003 i . .....�.