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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> SHADED SECTIONS FOR END USE ONLY OWNERID# �L' S� CASE# <br /> L OWNER FILE <br /> COMPLETE THEFOLLOWING BUSINESS OWNER INFORMATION: CHECK IF OWNER CURRENrtYON FILEWITH EHD <br /> BUSINESS a`sl,--a(r� a 4ti PHONE <br /> OWNER NAME <br /> First MI Last <br /> BUSINESS NAME(If ditferenlfromOwnerName) Q , SOc Sec orTax ID# <br /> (D h ` 2 2 <br /> OWNER HOME ADDRESS <br /> CITY STATE ZIP <br /> OWNER MAILING ADDRESS(If ittrerent frocuOwner Address) Attention orcare of <br /> OX 2 a <br /> MAILING ADDRESS CITY O $71,T6 ZIP <br /> TYPE OFOWNERSHIP: <br /> CORPORATION INDIVIDUAL❑ PARTNERSHIP❑ ,LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FEDAGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID#: CO-OWNER ID#: ACCOUNT ID#: <br /> COMPLETE THE FOLLOWING BUSINESS FACILITY INFORMATION: <br /> is this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES X NO ❑ <br /> Is this an EXISTING Business LOCATION but NEW TYPE Of regulated Business? YES ❑ NO <br /> + <br /> P <br /> BUSINESS/E&CILITY NAME IThls will Mn heyHERMIT) <br /> (/)" (2— <br /> FACILITY •,. <br /> '- <br /> ADDRESS FACILIris a MDeRE N�ror FDOD VEN.4Euse the COMMISSARY Anna , BUSINESS PHONE <br /> ll/ B/ n� <br /> 7Siaos7 Gv suite» (Z6 8098 <br /> CitTY(IfFAGulYMa Most Fo DUwor Food WmM usethecoMMiRRA CIrI $TAT ZIP <br /> C7 � 952 D <br /> BOARD OF SUPERVISOR DISTRICT / LOCATION CODE KEY1 KEY2 <br /> MAILING ADDRESS for Health Petmit(if DIFFERENTTrom Fae#ityAddress) Attention orCare Of <br /> C) 2-7 <br /> MAILING ADDRESS CITU STATE ZIP 9 ?z _ / ' <br /> SIC CODE: APN#: COMMFNT: <br /> 4=01INTAIDDRF.Q.Q for fees and Charges: OWNER ❑ FACILITY/BUSINESS <br /> RnTTNG AND Compt.tANcr AcKNowTEDGMENT; I, the undersigned Applicant, certify that I am the Owner, Operator, or Authorized Agent of this <br /> Business, and I acknowledge that all PERAHTFEES,PENAL7zes.ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation will be <br /> billed to me at the address identified above as the ACCOUNTADAReac for this site. I also certify that all information provided on this application is true <br /> and correct; and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Re Mations. <br /> APPLICANT NAME: SIGNATURE: <br /> Please Print <br /> TITLE: DATE DRIVER'S LICENSE# <br /> (PHOTOCOPY RFOLARF111 <br /> Approved By Date 3 ' Accounting Office Processing Completed By Date <br /> A PROGRAM (EHD 48-02-034 Pink) or WATER SYSTEM{EHD 46-02-003)form mttsf be completed for each EHD regulated operation &t th s I nC.ATInN <br /> except UST Program(Use SW RCB forms) <br /> EHD 48-02-035 Masterfile Record-Green <br /> 10/912003 <br />