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II ` io✓ SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORDi!NFORMATION FORM SwEDSEcnoNSFDREHD USEONLY OWNERlD# ' ` CASE OWNER FILE COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION: II CHFCKIF OWNER CuRRENTLYONRLEMTHEHD BUSINESS I PHONE OWNER NAME First M1 Last I i BUSINESS NAME(If different from Own Name) II c orTax ID# C� G � r Dr)I.r 0 h a s OWNER HOME ADDRESS 0 '2, CITY JCA I STATE ZIP �` 7 7 OWNER MAILING ADDRESS (If M76rent from Owner Address) f Attention orCare of y MAILING ADDRESS CITY I STATE ZIP TYPE OF OWNERSHIP: CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY FED AGENCY❑ OTHER❑ FACILITY FILE FACILITY ID#: CO-OWNER ID#: I`�, ACCOUNT ID#: COMPLETE THE FOLLOWING BUSINESS FACILITY INFORMATION; �I i Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ETM ONMENTAL HEALTH DEPARTMENT? YES NO ❑ Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? .f YES ❑ No ❑ BUSINESS/FACILITY NAME(This the UsINEssNAME the HEAL1 EgMl rI �I I �Y r rLr ^ V r+ FACILITY ADDRESS(1fFA Is a MosrtFFoogUsrrT OrF000 Vaa�use thKooiF B{�USINES�S^-P�HONF, CITY(IfFAaurYisaMoan.EFoonUM orFoonVEwicLEusetheCoMMrssnrevGirl ST Zip BOARD OF SUPERVISOR DISTRICT LOCATION CODE �F KEYI KEY2 MAILING ADDRESSfor Health Pelmit(IfDIFFERENTfromFacilifyAddress) ! AttentionorCare Of MAILING ADDRESS CITY STATE zip SIC CODE; APN#; TZ o CoMMEFIT; DJ ACCOMr-AMPESSforfees and charges: OWNER ❑ FACILITYBUSINESS ❑ Rni.mc. AND CoMPI.TANCF ACxNnu,t,Flx nrc.NT; I, the undersigned App6 ant, certify that I am the Owner, Operator, or Authorized Agent of this Business,and I acknowledge that all PERMIT FEES,PR'NALTiES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated withi this operation will be billed to me at the address identified above as the ACCQuNTADyREcc 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 CouNT'Y OAinance Codes and/or Standards and STATE andlor FEDERAL haws and Re ulations. APPLICANT NAME: ! SIGNATURE: Please Prfrat TITLE: DATE DRIVER'S LICENSE# i I :I Approved By Date Accounting Office Processing Completed By Dake 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 except UST Program(Use SWRCB forms) EHD 48-02-035 1019/2003 Masterfile Record-Green i fff