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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> SHADED SECTIONS FOR EHD USE ONLY OWNER 10 CASE# <br /> �I <br /> OWNER FILE <br /> COMPLETETHEFOLLOW/N(3 BUSINESS OWNER /NFORMAT/ON: CHECKiF OWNER CURREIva YON FILE WITH EHD1_1 <br /> BUSINESS �� �O ` PHONE <br /> OWNER NAME — IZ, <br /> First MI Last l oO l /j <br /> BUSINESS NAME(If different From Owner Name) Soc Sec orTax ID# <br /> OWNER HOME ADDRESS n <br /> - 03 <br /> CITY <br /> OWNER Mlgl(,IN,;ADo SS(H different from Owner Address) Attention orCare of <br /> MAILING ADDRESS CITY FSTAV ZIP , <br /> b <br /> TYPE OF OWNERSHIP: <br /> CORPORATION❑ INDIVIDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE [[ <br /> FACILITY ID#: 0 'S3 CO-OWNER ID#: ACCOUNT ID#: DI's —T3OO <br /> COMPL ETE THE FOL LOW/NG B US(N ES S FAC(L ITY/NFORMAT/ON.' <br /> ElhjsEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YESNO ❑EXISTING Business LOCATION but a NEW TYPE.of regulated Business? YES ❑ No tqt <br /> BUSINESS/FACILITY NAME(This will be the BUS/NESSAUMEOn the HEALTH PERMIT) <br /> FACILITY ADDRESS(If FAC/UrYis a MOBILE FOOD UN?or FOOD VEHICLEuse the G'OBUSINESS PHONE <br /> Suite# <br /> CITY(If FACIUTYis a MO&LE FOOD UNIT or FOOD VENCLE use the COMMISSARY CITY) STATE ZIP <br /> __FBOARD OF SUPERVISOR DISTRICT LOCATION CODE _ KEYI KE 12 <br /> MAILING ADDRESS for Health Pertmt(If DIFFERENTfrom FacdityAddress) Attention orCare Of <br /> MAILING ADDRESS CITY STATE ZIP <br /> SIC CODE: APN#: 05( 330 COMMENT:tA�--C,J <br /> AccoUA/T AIDDRF,QR for fees and charges: OWNER V FACILITY/BUSINESS ❑ <br /> 1311.1ING ANT) COMPI.IANCF ACKCiow'I.FDC;MFNT: I, the undersigned Applicant, certify that I am the Owner, Operator, or Authorized Agent of this <br /> Business, and 1 acknowledge that all PFRAmT FEES,PE.NALT/E.S,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation will be <br /> billed to me at the address identified above as the ACCOUATADDRFSS for this site. I also certify that all information provided on this application is true <br /> and correct; and that all regulated activities -.sill 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 /> Approved By Date Accounting Office Processing Completed By Date <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 I n_ A�TIO <br /> except UST Program(Use SWRCB forms) <br /> EHD 48-02-035 Masterfile Record-Green <br /> 10/912003 <br />