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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM SHADED SECTIONS MR EHD USE ONLY II OWNER ID# I n Jn1l7-) i/_ II CASE# OWNER FILE COMPLETE THEFOLLOW/NGBItRINFRc[1WNFR /u�nnuw rvni. ------ - "----• •'••-•••••^••"^• BuslNEss VH&GKIF UWINhK GURRENTLYONF/LEW/THEHDL,J PHONE: OWNER'S NAME First MI Lest 2(99 -35 -2 2B' BUSINESS NAME (If d#kmntrromO"er Name) OWNER'S HOME ADDRESS KEYI Cltt -� C.Yn KEY2 Sr ZIP o cO �3� OWNER'S MAILING ADDRESS (If diRerenthom ner's Address) Attention orCara oT 40 " 6w SIC CODE: 7 P4 G MAILING ADDRESS CITY ST ZIP - 171) TYPE OF OWNERSHIP: I CORPORATION ❑ INDIVIDUAL IQ PARTNERSHIP ❑ LOCAL AGENCY ❑ COUNTY AGENCY ❑ STATE AGENCY ❑ FED AGENCY OTHER ❑ FACILITY FILE FAIauttID#: p02,3CO-OWNERID#: ACCOUNT ID#: lam/ L COMPLETE THEFOLLOW/NG BUSI N ESS FACI LITY /NFORMATrON* Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES NO ❑ Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No BUSIyE38/FACILITY AME (This Will be the BUs $NAMEon the HEALTH RMT) FACILITY ADDRESS (If FAC2RYle a MOBILEFo00 UNROr FOOp VeHicceuea the COMMISSARY ADDRESS) 30f( S Ll gotrajo CITY (if FAduTYIS a MOBILE FOOD UNIT or FOOD VEHICLE use the COMMISSARY Cr ) foe suite # STATE BUSINESS PHONE i ZIP BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEYI KEY2 MAILING ADDRESS for Health Perm%ttOIFFFEERE/y� m Fac/I/tyAddressJ I x c- d Attention orCare Of Q r� J MAILING ADDRESS CITYL..it � STATE C ZIP SIC CODE: APN P. COMMENT: ACCOUNTAODRESSforfees and charges: OWNER ❑ FACILITY/BUSINESS BILLING AND COMPLIANCE ACKNOWLEDGMENT: I, the undersigned Applicant, certify that I am the Owner, Operator, or AuthorieirAgent 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 ACCOUNT ADDRESS 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 II APPrewd By ,I 1\I I , I Oete '-) -) -1 1 % n II Aacmnling Omw Pracswing COmPlstsd By I Dots 3/,'/J-7 A PROGRAM (EHD 48-02-034 Pinky Or WATER SYSTEM (EHD 46-02.003) form must be completed for each EHD regulated operation at this LOCATION except UST Program (Use SWRCB forms) EHD 48-02-035 Masterf le Record -Green 8/19/08