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SAN JOA'7y ''N COUNTY ENVIRONMENTAL HEALTH r'-'ARTMENT <br /> IVIASTERFILE RECORD INFORMATION FORM <br /> SHADED SEC77ONSFOR EHD USE ONLY OWNER ID# CASE# <br /> ' OWNER FILE <br /> COMPLETE THE FOLLOWING BUSINESS OWIN49RNfORMATION.' OfECKtFOWNER CURRENTIr0NFILEWTMEHD❑ <br /> BUSINESS ONE' <br /> OWNER'S NAME First Mt Last <br /> BUSINESS NAME(If different from owner f arae) Soc Sec orTax ID# <br /> OWNER'S HOME ADDRESS 9 $5'.r <br /> CITY C /: ST Z1P <br /> OWNER'S MAILING ADDRESS (If different from Owner's Address) Attention orCare of <br /> MAILING ADDRESS CITY STATE ZIP <br /> TYPE OF OWNERSHIP: <br /> CORPORATION❑ INDIVIDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ <br /> p FACILITY FILE <br /> =FACILITY #: ( CO-OWNER ID#: ACCOUNT ID#: <br /> COM04RM THE FOLI OWING <br /> Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No ❑ <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ❑ <br /> BUSINESS/FACILITY NAME(Thi will be the aw7NEs4NAMEOn the H PERMIT) — <br /> !"✓ 0 <br /> FACILITYADDRE5S(If Fa isat*wrF FcocUIvrrorFcmaU Iuseth��r�M��6r�s].� � �ZSIN PHONE <br /> 7a <br /> 5026t Ali guber. 0jh Suite# <br /> CITY(If FACfLFrYls a MOBILE FOOD UNrror FOOD VEHICLE use the r ommissARY Cnvl STATE ZIP <br /> BOARD OF SUPERVISOR DisTRICr LOCATION CODE =EY1 KEY2 <br /> MAILING ADDRESS for Heaft Permit(If DIFFERENTf rn FaalityAddre,1s) Attention orCare Of <br /> MAILING ADDRESS CITY STATE ZIP <br /> SIC CODE: APN#: COMMErrr: <br /> FACC=0146MAIDDRFcc for fees and charges: OWNER ❑ FAc[LITY/BuslNEss ❑ <br /> BILLING ANn COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that 1 am the Owner,Operator,or Authorized Agent of this Business,and <br /> I acknowledge that all PERMIT FEES, PENALTIES, ENFORCEMENT CHARGES and/or HOURLY CHARGES associated With this operation will be billed to me at the <br /> 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 <br /> all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or <br /> FEDERAL Laws and Reciulations. <br /> PPLICANT'S AME' SIGNATUREd <br /> Please Print <br /> TITLE: DATE DRIVER'S LICENSE# <br /> 4PHOTOCOPY REQUIRED) <br /> Approved By ��- Date// Accounting Office Processing Completed BY Date JB <br /> 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 <br /> I OCATION except UST Program(Use SWRCB forms) <br /> EHD 48-02-035 Masterfile Record-Green <br /> 8/19/08 <br />