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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MIASTERFILE RECORD INFORMATION FORM SHADED SECTIONS FOR EHD USE ONLY OWNER ID# �D `] CASE# l OWNER FILE COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION: CHECKIF OWNER CURRENTLY ONFILEWITHEHD BUSINESS OWNER NAME S/,} O G 170 d L I G q D P,-e)9 PHONE First Ml Last BUSINESS NAME(Ii different from owner Name) Soc Sec or Tax ID# 22 C- IIlr.,nL/4J �� 5- OWNER OWNER HOME ADDRESS CITY STATE ZIP OWNER MAILING ADDRESS (If different from Owner Address) Attention or Care of MAILING ADDRESS CITY STATE ZIP TYPE OF OWNERSHIP: CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ FACILITY FILE FACILITY ID#: ' CO-OWNER ID#: ACCOUNT ID#: O COMPLETE THE FOLLOWING BUSINESS FACILITYINFORMATION: IS this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO ❑ Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ NO ❑ BUSINESS/FACILITY NAME(This will be the BUSINEssNAME on the HEALTH RMI o� / 7` FACILITY ADDRESS If ot4iXisaMoBILEFoODUNtrorFoODVEHICLEusetheCOMMissaRYA BUSINESS PHONE Numr Drection SirreetName RtTvnp Suite# CITY(If&ctuTYIs a MOBILE FOOD UNITor FOOD VEHICLE use the COMMISSARY CIT') STATE ZIP BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEYI KEY2 MAILING ADDRESS for Health Permit(If DIFFERENT from Facility Address) Attention or Care Of MAILING ADDRESS CITY STATE ZIP SIC Co.-- APN#: COMMENT: A(C nIINT dDDRFSS for fees and charges: OWNER ❑ FACILITY/BUSINESS ❑ Bui.LiNc AND CoNmIANCE ACRNONVI.FDGMRNT: 1, the undersigned Applicant, certih, 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 is-ill be billed to me at the address identified above as the ACCOUNTAnnRFcs 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: SIGNATURE: Please Print TITLE: DATE DRIVER'S LICENSE# (PHOTOCOPY REQUIRED) Approved By Date Accounting Office Processing Completed By DateIrk I 7 D 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 LOCATION except UST Program(Use SWRCB forms) EHD 48-02-035 Masterfile Record-Green 10/9/2003