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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM SHADED SECTIONS FOR EHD USE ONLY OWNER ID# 0 2I `S 7/ CASE# OIRMER FILE COMPLETE THE FOLLOWING BUSINESS OWNER INFORMAT/ON; CHECK/F OWNER CURRENTLYONFILE wITHEHD❑ BUSINESS PHONE: OWNER'S NAME First MI Last BUSINESS N ME(If different from Owner Name) Soc Sec or Tax ID# OWNER'S HOMEADDRESS CITYSTATE ZIP F'fl� '�')S OWNER'S MAILING ADDRESS (If different rfrom Owner's Address) Attention orCCare of J� / 0 , ,�9C MAILING ADDRESS CITY STATE ZIP GnZnn4_ O TYPE OF OWNERSHIP: CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY FED AGENCY OTHER❑ FACILITY FILE FACILITY ID#: CO-OWNER ID#: ACCOUNT ID#: A40011_2Gfs,�l COMPLETE THE FOLLOw/NGBUSI NESS FACILITY INFORMATION: Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONFIENTAL HEALTH YEsu No ❑ neo.—1--1 Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ❑ BUSINESS/FACILITY AME(This will be the AquswEss NAmEon the H;4TH PERMIT) FACILITY ADDRESS(If FACIL17Yis a MOB/LE FooD LWITor FOODEH/CLEuse the COMMISSARY ADDRESS),/� BUSINESS PHONE ) L Street Number Direction Street Name Street T- Suite# CITY(ICf FACILITYIS a MOBILE FOOD UNn-or FOOD VEHICLE use the COMMISSARY CITY) STATE zip^% c BOARD OF SUPERVISOR DISTRICT /r LOCATION CODE (7l KEY1 KEY2 MAILING ADDRESS for Health Perm t(iff,DIFFERENTfrom Facility Address) Attention orCare Of c� x ! "::/ MAILING ADDRESS CITY STATE ZIP C tti,c.-4 c' 1/-d % y2c� g SIC CODE: APN#: Q 7 I D D 7�p COMMENT: ACCOUNTAOORESS for fees and charges: OWNER ❑ FACILITY/BUSINESS BILLING AND COMPLIANCE ACKNOWLEDGMENT: 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 ACCOUNTADDRESS 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'S NAME: SIGNATURE: Please Print TITLE: DATE DRIVER'S LICENSE# PHOTOCOPY REQUIRED Approved By Date Accounting Office Processing Completed By Date A PROGRAM{EHD 48-02-034 Pink)or WATER SYSTEM{EHD 46-02-0031 form must be completed for each EHD regulated operation at this LOCATION except UST Program(Use SWRCB forms) EHD 48-02-035 Masterfile Record-Green 8/19108