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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM SHADED SECTIONS FOR EHD USE ONLY 'EOWNER�1114 CASE# OWNER FILE COMPLETETHEFOLLOWINGBUSINESS OWNER INFORMATION; CHEctCIF OWNER CURRENTLYONFILE wITHEHD❑ BUSINESS /// PHONE: OWNER'S NAME (�V 20-? SIC^ �z 1141 L BUSINESS NAME(If different from Owner Name) Soc Sec orTax ID# OWNER'S HOME ADDRESS 2 TO P-t CITY kM �( ST zip q52�OWNER'SING ADDRESS (If different from Owner's Address) Attention or Care of MAILING ADDRESS CITY STATE zip TYPE OF OWNERSHIP: CORPORATION❑ INDIVIDUAL APARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY OTHER❑ FACILITY FILE FACILITY ID#: CO-OWNER ID#: ACCOUNT ID#: COMPLETETHEFOLLOWINGBUSINESS FACILITY INFORMAT/ON: 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 ❑ BUSINESS/FACILITY NAME(This will be the BUS/NESS NAMEon the HEALTH PERMIT) Ynw�601(01 Y 11 (� ✓f 111 FACILITY ADDRESS(If FA IL1TYis a MOBILE FOOD UN17or FDOo VEHICLE use the COMMISSARY ADDRESS) BUSINESS PHONE 4`0 C. v�Uf�()ov PC)ber Street Name Street T—, Suite# ZU'%J S4& -2&2q CITY(If FACILITY IS LE FOOD U or FODD VEHICLE uSe the COMMISSARY CITY) STATED zip c k.- , n C LV BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 MAILING ADDRESS forHealth PerTTIIt(If DIFFERENTfrom FacilityAddress) entio or Care Of 1 -1-62— Or D U iU� MAILING ADDRESS CITY �/� ;' STATE SIC CODE: APN#:I U , COMMENT: ( G(J ACCOUNTADDRESS 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: V`vl V�t SIGNATURE: Z r Please Print ^I/, D / (f TITLE: I U DATE (/// UX DRIVER'S LICENSE# o PHOTOCOPY REQUIRED Approved By Date Accounting Office Processing Completed By Date 4 PROGRAM{EHD 48-02-034 Pink}or WATER SYSTEM{EHD 46-02-003}form must be completed for each EHD regulated operation at this LOCATION :xcept UST Program(Use SWRCB forms) -HD 48-02-035 Masterfile Record-Green 3/-19/08