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SAN J*IN COUNTY ENVIRONMENTAL HEALTH PARTMENT C� MASTERFILE RECORD INFORMATION FORM / SHA DEDSECTNJNSFOR EHD USE On OWNERID# CASE#. OWNER FILE COMPLETE THEFOLLOw/NG BUSINESS OWNER INFORMATION: CHECK/F OWNER CURRENTL YON FILE w/THEHD❑ BUSINESS PHONE: 00,y OWNER'S NAME i First MI —Last � �7 BUSIN SS NAME(If differentfremOwner Name) ,� Soo Sec orTaX ID# Yc / y ^ I1/0- OW 'S HOME ADDRESS D ZZ Q n O Cm O �� STT zip f OWNER'S MAILING ADDRESS(Ifd#farenttr' Ownaes Address) Attention orCare I. Q,IrQ- A4. M e' f C MAILING ADDRESS CITY STATE ZIP TYPE OF OWNERSHIP: CORPORATION INDIVIDUAL El PARTNERSHIP F] LOCAL AGENCY COUNTYAGENCY❑ STATE AGENCY I—] FED AGENCY El OTHER El FACILITY FILE FAC WTY ID#: CO-OWNER ID#: ACCOUNT ID#: COMPLETE THEFOLLOw/NG BUSINESS FACILITY/NFORMAT/ON.' 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 h9. BUSINESS(FACILITY NRME(This will be(he Gvsivess on the HEALTH PERMIT) !t/ OF FACILITY ADDRESS(if FACILRYie a MoalLeFood UHlror FOOD VEHcL use the COMMISSARYADDREssI BUSINESS PHONE /� 5 q,k 0 (/�— Suite# CITY(if FAciu maM=LEFooD UNrror FOOD,VEHICLEMse the COMMISSARY CmI STATE ZIP BOARD OF SUPERVISOR DISTRICT LOCATION CODE KW KEY2 MAILING ADDRESS for Health Perm%t(If DIFFERENTfrom Facility Add ese) Attention orCare Of MAILING ADDRESS CITY STATE zip SIC CODE: APN#: COMMEM: ACCOUNTADORESS for fees and charges: OWNER ❑ FACIDTYIBUSINESS ❑ 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 Pnnt TITLE: DATE DRIVER'S LICENSE# PHOTOCOPY REQUIRED) Approved By Date Accounting Office Processing Completed By Data A PROGRAM(EHD 48-02-034 Pink)or WATERSYsFENt(EHD 46-02-003)form must be completed for each EHD regulated operation at this LOCATION except UST Program(Use SWR orms ` EHD 48-02-036 ,r ,,� 1 Masterfile Record-Green 11127107 �//G