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SAN JOA N COUNTY ENVIRONMENTAL HEALTH ' -ISION OWNER • FACILITY *ACCOUNT* MASTERFILE RECORD INFORMATION FORM (EH 0015 REVISED 812/1999) SHADED SECTIONS FOR EHD USE ONLY OWNER ID# OWlaaa 11 CASE# OW OWNER FILE j COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION: CHECKIF OWNER CURRENTLY ON FILE WITHFHDI I BUSINESS4A� OWNER NAME Firs Mt I Last PHONE BUSINESS NAME (If different from Owner Name) Soc Sec or Tax ID # OWNER HOME ADDRESS Driver's License # CITY STATE ZIP OWNER MA I G�D SS f differenthr Own dress) V Attention or Care of MAILING ADDRESS CITY 1 /� Dj STATE �' Qy ZIP r%/{ TYPE OF OWNERSHIP: CORPORATION ❑ INDIVIDUAL ❑ PARTNERSHIP ❑ LOCAL AGENCY ❑ COUNTY AGENCY ❑ STATE AGENCY ❑ FED AGENCY ❑ OTHER ❑ FACILITY FILE FACILITY ID #: FA f .,---4)V7U I OWNER ID #: OW I ACCOUNT ID #: AR /" A I' I VI I CO-OWNER ID #: OW I COMPLETE THE FOLLOWING BUSINESS FACILITYINFORMATION: IS this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DIVISION? YES ❑ NO ❑ IS this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ NO ❑ BU S/FACILI E (This will be the BusiNESS NAME on the HEALTH PERMIT) Uc 16 MAILING ADDRESS FACI ^R_ESS (If FACILITY is Moe/LE FOOD Street m6er DirectiN, U ITO COD VEHICLE use the COMMISSARY ADDRESS) Street Name Street Type Suite # BUSINESS PHONE CITY (IfCq ILIFf Is a MoijtVF6oD UNIT or FOOD VEHICLE use the COMMISSARY CITY) STA TEr l/ / ZIP /� ✓� o BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 MAILING ADDRESS for Health Perinit(If DIFFERENTfrom Facility Address) Attention or Care Of MAILING ADDRESS CITY STATE 72IP SIC CODE: APN M COMMENT. THIRD PARTY BILLING INFORMATION: Complete if Billing Party is different from Business Owner Identified above. BUSINESS NAME Attention or Care Of MAILING ADDRESS PHONE CITY STATE ZIP ACCOUNT ADDRESS for fees and charges: OWNER FACILITY/BUSINESS ❑ THIRD PARTY BILLING ❑ 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 ACCOUNT ADDRESS 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 NAME: Please Pnnt SIGNATURE: 11 Approved By I Date II Accounting Office Processing Completed By 4>11 I Date 4+""J`/I UL) A PROGRAM {EH 0069 Pink) or WATER SYSTEM (EH 0069 Blue) form must be completed for each EHD regulated ooration at this LOCATION except UST Program (Use SWRCB forms) EH 0015 MFR Green Form.DOC