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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM SHADED SECTIONS FOR EHD USE ONLY OWNER ID III 0/) 00_ 121 �771 CASE# OWNER FILE COMPLETE THEFOLLOW/NG BUSINESS OWNER INFORMATION: CHECKtF OWNER CURRE•VrzvO F&EW1TNEHD BUSINESS DI / v /Q rr PHONNE OWNER NAME First Ml last 4G — BUSINESS NAME(If different fr Owner Name) Sm Seco Tax ID# OWNER HOME ADDRESS �� VlJ• CI CITY S A ZIP C OWNER MAILING ADDRESS(if different from Owner Address) Attention.,Care of MAILING ADDRESS CITY STATE ZIP TYPEOF OWNERSHIP: CORPORATION INOIVIDUA PARTNERSHIP❑ LOCAL AGENCY El COUNTY AGENCY El STATE AGENCY El FED AGENCY El OTHER FACILITY FILE FAauTYID#: F00.23 Lf IS CO-OWNER ID#: ACCOUNT ID#: 004-/ S OMAETE THE FOLLOW/NO SU S IN ES S FACILITY INFORMATION: IS this a NEW Business LOCATION Or VEHICLE net previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES NO ❑ Is this an ExISTING Business LOCATION but NEW TYPE of regulated Business? YES ❑ NO BUSINESSTACILITY NAME(This will be the HusrNESS NAMEOn the HEALTH PERMIT) FACILITY ADDRESS(if FACLnris a MOMLEFaoo UMV-or Food VE LEOse the COMMa<.RY Artsl u) (NESSPHONE /�J'DI W C'l2�rt� W CRY FAautruallfoelLE r-000 Uwror Fooa VENrxEuse the rn••aasa• mn S7q� ]Ips/ G -000 C ' G BOARD OF SUPERVISOR DISTRICT LOCATION CODE tYiP-77 KEY1 KEY2 MAILING ADDRESS for Health PerHNt(If DIFFERENTfrom FacWyAddress) Attention a Care Of MAILING ADDRESS CITY STATE ZIP SIC CODE: APN#: .3o 3r7 OOMMnrt: ACC0i1Nr4DDRE5SfOr fees and charges: OWNER FACILITYIBUSINESS ❑ FULLING AND COMPI TANCT ACKNOWLEDGMENT: 1, the undersigned Applicant, certify that I am the Owner, Operator, or Authorized Agent of this Business, and 1 acknowledge that all PERMIT FEES,PENALIZES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation will be HIM to me at the address identified above as the ACC'OUNTADDRECc 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 Regulations. APPLICANT AME: SIGNATURE: Please Pant TITLE: DATE DRIVER'S LICENSE If Approved Bounting Office Processlg Completed By Date I/IO A PROGRAM{EHD 48-02-034 Pink) or WATER SYSTEM(EHD 4602-003)form must be completed for each EHD regulated operation at this I OCATION except UST Program(Use SWRCB forms) EHD 48-02-035 Masterfile Record-Green 101912003