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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM SHADED SECTIONS FOR EHD USE ONLY OWNER ID # I r� 1�1 /6_/ S f CASE # nuuwaoa13 rn r COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION: CHECK IF OWNER CURRENTLY ONFILE WITH EHD YES ❑ NO ❑ BUSINESS OWNER NAMEI—M, i' /� G % r PHONE 9 / ✓V First BUSINESS PHONE � ! ` 3 -S Last BUSINESS NAME (If different from Owner Name) STIa.TE . Soc Sec or Tax ID # OWNER HOME ADDRESS' 9 BOARD OF SUPERVISOR DISTRICT L / CITY / D C, /�,emsA O G. � STATE ZIP J OWNER MAILING ADDRESS (If different from Owner Address) Attention or Care Of Attention or Care of MAILING ADDRESS CITY STATE STATE ZIP YPE OF UWNERSHIP: CORPORATION LJ INDIVIDUAL PARTNERSHIP ❑ LOCAL AGENCY ❑ COUNTY AGENCY ❑ STATE AGENCY ❑ FED AGENCY ❑ OTHER ❑ FACILITY FILE FACILITY ID #: 961 16r,96-3CO-OWNER ID #: ACCOUNT ID #: 9103- rrimpt FTF TNF rnt i nwipit_ RI IQIAICQQ CA (-II ITV Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? Is this an EXISTING Business LOCATION but a NEW TYPE •of regulated Business? YESIk NO ❑ YES ❑ NO ❑ BUSINESS/FACILITY NAME (This will be a BuswEssNAMEon the HEALTH PERMIT) / , _j 1:_5 ^ F— K O C C KOA-lY FACILITY ADDRESS (If FAC is a MOBILEFOOD UNr or FOOD VEHICLEuse the t'OMMIssARY ADDR S ) tvIv t 3 Number ivion t N St T Suite # BUSINESS PHONE � ! ` 3 -S CITY (IfFAGUTYIs a MOBILE FOOD UNIT or FOOD VEHICLE use the CoMMissGRY CITy) STIa.TE . BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEYI KEY2 MAI LING ADDRESS for Health Permit (If DIFFERENT from Facility Address) Attention or Care Of MAILING ADDRESS CITY STATE Zip SIC CODE APN #: COMMENT: for fees and charges: OWNER ❑ FACILITY/BUSINESS J BILLING AND COMPLIANCY ACKNcl1l'I rDCNIYNT: I, the undersigned Applicant, certify that I am the Owner, Operator, or Authorized Agent of this Business, and I acknowledge that all PERAfIT FEES', PENALT/ES, ENFORCEhIENTCIIARGEs and/or HOURLYCIfARCES associated with this operation Will be billed to me at the address identified above as the ACCOUNTAnnRF-,S;c 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 Cndec and/nr standards and STATE: and/or FEDERAL Laws and RQulations. - ----------- APPLICANT NAME: SIGNATURE: Please Print TITLE: DATE DRIVER'S LICENSE # Approved By Date Accounting Office Processing Completed By �: Date 2 A PROGRAM (EHD 48-02-034 Pink) or WATER SYSTEM (EHD 46-02-003) form mast 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