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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> 06J0(U �i(F 71 <br /> SHADED SECmsFOREHD USE ONLY OWNER ID# CASE# <br /> OWNER FILE <br /> COMPLETE THEFOLLOW/NGBUSINESS OWNER /NFORMAT/ON.' CHECKIF OWNER CURRENTLYONF EW/TTHEHD <br /> BUSINESS —Da d D PHONE / <br /> OWNER NAME /� <br /> First M1 Last qe_2—/ <br /> BUSINESS NAME(If different from Owner Name) SOC Sec orTax ID# <br /> 0 o n s <br /> OWNER HOME ADDRESS <br /> CITY STATE ZIP <br /> OWNER MAILING ADDRESS(If different fromgwner Address) Attention orCare of <br /> MAILING ADDRESS CITY � C ZIP , <br /> TYPE OF OWNERSHIP: (Q <br /> CORPORATION INDIVIOUA PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ <br /> ^A FACILITY FILE <br /> FACILITY ID#: t'/ CUD �J CO-OWNER ID#: ACCOUNT ID#: <br /> COMPLETE THE FOLLOW/NG BUSINESS FACILITY INFORMATION- <br /> Is this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES NO ❑ <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YE No <br /> BUSINESS/FACILITY NAME(This w'I be the BUSINESS! EOn HEALT PERMIT) <br /> FACILITY ADDRESS(If FACIL/TYIS a MOBILE FOOD LINiror FOOD VEHicteuse the CO MtiS ) BUSINESS PHONE <br /> �y 2 S � ra� S`t• <br /> Suite# <br /> CITY(If FAauTYIs a MoeuFFooD UNrT Or FOOD VEHICLE use the CommissARY Ct ST ZIP <br /> G CY4 7f 51?6 4:01 <br /> BOARD OF SUPERVISOR DISTRICT rl LOCATION CODE KEYI KEY2 <br /> MAILING ADDRESS for Health PeFn7 t(If D/FFERENTfrom Facility Address) Attention orCare Of <br /> PC) 130X �3�� <br /> MAILING ADDRESS CITY S { STAT LL ZIP <br /> SIC CODE: v APN#: ' w�r 1 r COMMENT: TT <br /> A TADDRF.S.S for fees and charges: OWNER ❑ FACILITY/BUSINESS <br /> Rn.I.ING AND COMPI.mcF. AcKNoNA i.YDGMENT: I, the undersigned Applicant, certify that I am the Owner, Operator, or Authorized Agent of this <br /> Business, and 1 acknowledge that all PERn,11T FEts,PENALTTE.S,ENFORCEMENT CffARGES and/or HOURLY CHARGES associated with this operation will be <br /> billed to me at the address identified above as the ACCOUNTADnR_F.cs for this site. I also certify that all information provided on this application is true <br /> and correct; and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or <br /> Standards and STATE:and/or FEDERAL,laws and Regulations. <br /> APPLICANT NAME: SIGNATURE: <br /> Please Print <br /> TITLE: DATE DRIVER'S LICENSE# <br /> (PHOTOCOPY REouigrnl <br /> Approved By 27 IV Date Accounting Office Processing Completed ByDate <br /> 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 LDCATION <br /> except UST Program(Use SWRCB forms) <br /> EHD 48-02-035 Masterfile Record-Green <br /> 10/9/2003 <br />