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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 9STERFILE RECORD INFORMATION FORD SHADED SECTIONS FOR EHD USE ONLY OWNER ID# QO CASE# OWNER FILE COMPLETETHEFOLLOWING BUSINESS OWNER INFORMATION: CHECK/F OWNER CURRENTLYONF/LEWITHEHEI BUSINESS ha L PHONE OWNER NAME First MI Last ��9 ftle-9900 BUSINESS NAME(If diAerentbwn Owner Name) Soo Seo-,Tax ID# OWNER HOME ADDRESS CITY STATE ZIP OWNER MAILING ADDRESS(If dlllerent liomOwner Address) ANention-,Care of MAILING ADDRESS CITY STATE ZIP TYPE OF OWNERSHIP: CORPORATION El INDIVIDUALk PARTNERSHIP❑ LOCALAGENCY❑ COUNTYAGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ FACILITY FILE FACILITY ID M CO.OWNER ID#: ACCOUNT ID#: COMPLETE THEFOLLOWING BUSINESS FACILITY INFORMATION.- IS ti113 aNEW BD$ine$$LOCATION Or VEHICLE n0[previously regulated by We ENVIRONMENTAL HEALTH DEPARTMENT? YES NO ❑ IS tiIIS an EXISTING Business LOCATION but NEW TYPE Of regulated Business? YES ❑ ND�K. BUSINESS/FACILITY NAME(This will be the Ruswesa NAmaon the HEALTH PERMIT) o/o r rb FACILITY ADDRESS(if FAatmis a M-eldeFOoo UAvror FOOD VEHictEDse the COMMISSARY ADDRESS/ BUSINESS PHONE 1020 L� Ch St- (zo9)q�f-51"70DSuite# CITY is a MmLeFooD Owror F000 Vemraeuse the t'omw<%mr C.Y) STATE ZIP BOARD OF SUPERVISOR DISTRICT LOCATION CODE D/ KEY1 KEY2 MAILING ADDRESS for Health Pert fiff DIFFe-RENTfrom Facility Address) Attention orCare Of MAILING ADDRESS CITY - STATE ZIP SIC CODE: APN#: I� i2 ia3 COMMENT: ACCOUNTADORFRR for fees and charges: OWNER ❑ FACILITY/BUSINESS Rna.uaG AND COMPI iANCE 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,PENALitES,ENFORCEMENTCHARGE.S and/or HOURLY CHARGES associated with this operation will be billed to me at the address identified above as the ACCOUNTADDRecc 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 Re ulations. PPLICANT NAME: SIGNATURE: Please Pent TITLE: y� DATE DRIVER'S LICENSE# Approved By Dale p 2� Accounting Office Processing Completed By Date x / 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 I OCIATIC)N except UST Program(Use SWRCB forms) EHD 48-02-035 Masterfile Record-Green 10/9/2003