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SAN JOAN COUNTY ENVIRONMENTAL HEALTH DORTMENT MASTERFILE RECORD INFORMATION FORM SNAD£DS£CT/ONSFOREHDUSEONLY OWNER ID# / CASE# OWNER FILE COMPLETE THEFOLLOWING BUSINESS OWNER INFORMATION.' CHEcN IF OWNER CURRENTLY oNF&E wi7H EHD❑ BUSINESS PHONE: OWNER'S NAME First MI Last BUSINESS NAME(If dilferentfrom Owner Name) SOD Sec or Tax ID# s� DSI-F-• co/ Q ¢- OWNER'S HOME ADDRESS CITY STATE zip OWNER'S MAILING/ADDRESS (If different from,Owner's Address) Attention orCare of SIS ( PA-XyL Vel /✓10 MAILING ADDRESS CITY STATE zip O TYPEOFOWNERSHIP: CORPORATION El INDIVIDUAL El PARTNERSHIP El LOCAL AGENCY❑ COUNTY AGENCY Ll STATEAGENCY❑ FED AGENCY El OTHER El FACILITY FILE FACILITY ID#: c l CO-OWNERID#: ACCOUNT MAR pj2_1? 4d COMPLETE THEFOLLOWING BUSINESS FACILITY INFORMATION: 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 ❑ BUSINESS/FACILITY NAME(This will be the aUswN SNAMEOn the HEALTH PERMIT) Co ( e J 1 twsa� FACILITY ADDRESS(if FAcmurris a MOEILEFOOD UMffor F000 2VEh%C4EUS.pa the COMMISSARY ADDREssI BUSINESS PHONE 07 7 �'� ( 4 srkWa �Z13 Suite CITY(if FACmur is a MostLEFOOD UNrror Fow VEHICLEuse the COMMISSARY Cm) STATE zip �aMr )rH 0>ti5-- 1 G 45�539 / BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 MAILING ADDRESS for Heap/Perm^ft(If DIFFERENTfrom Facility Address) Attention orCare Of Cj 15 1 e�-, 4- /9 V-— T/rno/cl MAILING ADDRESS CITY $TATE/•Iq ZIP Zo SIC CODE: APN#: 'Zo 9 C9 IJp COMMEM: C_ ACCOUNTADORESSfor fees and charges: .J 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 Regulations, APPLICANT'S NAME: SIGNATURE: Please Print TITLE: DATE DRIVER'S LICENSE# PHOTOCOPY REQUIRED Approved By Date Accounting Office Processing Completed By Data , Z A PROGRAM(EHD 48-02-034 Pink)or WATER SYSTEM(EHD 46-02-003)form must be completed for each EHD regulated operation at this LOCATION except UST Program(Use SWRCS forms) EHD 48-02-035 Masterfile Record-Green 11127107