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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM SHADED SECTIONS FOR EHD USE ONLY OWNER ID# 0000.23I a5 CASE# V GVOWNER✓FI(L/E COMPLETE THEFOLLOw/NG BUSINESS OWNER INFORMATION: CHEcAr iF OWNER CuRRENTL PON FiLE wirH EHD❑ BUSINESS pm5 e rya �� OWNER'S NAME /� First MI Last r L Q BUSINESS NAME(If different from Owner Name) SOe Sec orTax ID# 1<c L eoLSin Gory /� L OWNER'S HOME ADDRESS Rom te i/ t 7fe-e- , CITY NU AIX 763 Sr z2 aP - 63E OWNER'S MAILING ADDRESS (If di rent from Owner's Address) Attention or Care of MAILING ADDRESS CITY STATE zip TYPE OF OWNERSHIP: CORPORATION NK INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY OTHER❑ FACILITY FILE FACILITY ID#: p '�-1-f--52j CO-OWNERID#: ACCOUNTID#: PQPDD �$797j COMPLETE THE FOLLOW/NG BUSI NESS FACILITY INFORMATION. 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 RusINES9NavEon the HEALTH PERMIT) r�5'C'e ora4-p Lcai S FACILITY ADDRESS FAC/L/TY I9 a MoSme FOOD UNnor FOOD VEN LEuse the COMMISSARY ADDRESS) BUSINESS PHONE 7go9 W AtAod 4&-b— Diro�tion SD;te# 2°q'�33f�-8737 CITY(IffFncl� ITY IS a MOa1LEFOOD UNrror FOOD VEHIcLEuse the COMMISSARY C ) STATE, zips BOARD OFSUPERVISOR DISTRICT LOCATION CODE KEY1 C/AI KEY2 775/S MAILING ADDRESS for Health Permit(If DIFFEREArTfrom Facility Address) Attention orCare Of MAILING ADDRESS CITY STATE zip SIC CODE: APN#: COMMENT: 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 Regula '4 S. \\((��JJ� � � �� APPLICANT'S NAME: �--cl�-+✓`^-�-• SIGNATURE: Pleasd Print TITLE: DATE3 �.. DRIVER'S LICENSE# /Z I� PHOTOCOPY REQUIRED Approved By Geta Accounting Office Processing Completed By 56 Date -2) )III 4 A PROGRAM(EHD 48-02-034 Pink)or WATER SYSTEM(EHD 46-02-003)farm must be completed for each EHD regulated operation at this LOCATION except UST Program(Use SWRCB forms) EH D 48-02-035 Masted le Record-Green 8119108