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SAN JOOJIN COUNTY ENVIRONMENTAL HEALTH *RTMENT MASTERFILE RECORD INFORMATION FORM SHADED SECTIONS FOR EHD USE ONLY OWNERID# df�o0133USCASE# OWNER FILE COMPLETE THEFOLLOWING BUSINESS OWN ER INFORMATION.' CHEcH iF OWN ER CURRENTL✓ONFiLEWITH EHD❑ BUSINESS PHONE: � OWNER'S NAME First MI Last �� BUSIN 55 NAME(If d=erentlrom Owner Name) Soc Sec orTax ID# ♦ lY OW14E&S HOME ADDRESS Z_qp Q r C CMY O �/� ST : ZIP OWNER'S MAILING ADDRESS (if different from Owner's Address) Attendon /o CareC /C [ MAILING ADDRESS CITY STATE zip TYPE OF OWNERSHIP: CORPORATION Et INDIVIDUAL F-1 PARTNERSHIP El LOCAL AGENCY E] COUNTY AGENCY F-1 STATE AGENCY El FED AGENCY El OTHER El if FACILITY FILE FACILITY ID#: 37 CO-OWNERID#: ACCOUNTID#: COMPLETE THE FOLLOWING BUSINESS FACILITY INFORMATION: Is this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES NO El Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No tg. BUSINEsSIFACILITY NAME(This will bethe Busovess Ammon the HEALTH PERMIT) !//d FACILITY ADDRESS(Ifu FACIisa Moe2eF000 Unrror F000✓erocieuse the COMMISSARYADDRESsI BUSINESS PHONE X7 5 ,vk P V� Suits# CITY(If F=uTYis a MOSILE FOOD UMTor FOOD VEHICLE use the COMMISSARY CM1 $TATE zip BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 MAILING ADDRESS for Health Permit(If DIFFERENTfrom FaeilityAddress) Attention orCom Of MAILING ADDRESS CITY STATE ZIP SIC CODE: APN#: COMMENT: ACCOUNTADORESS for fees and charges: OWNER ❑ FACILITYIBUSINESS ❑ 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 Regulations. APPLICANT'S NAME: SIGNATURE: Please Print DRIVER'S LICENSE# TITLE: DATE PHOTOCOPY REQUIRED Approved By Date 11 Accounting Office Processing Completed By Date A PROGRAM(EHD 46-02-034 Pink)or WATER_RWTM(EHD 46.02-003)form must be�completed for each EHD regulated operation at this LOCATION except UST Program(Use SWR orms EHMasterfile Record-Green 11/27/0727/07 I�, 7/07 -035