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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> SHADED SECTIONS FOR EHD USE ONLY OWNER ID# o&)oo a3/SI CASE# <br /> OWNER FILE <br /> COMPLETE THE FOLLOw/NG BUSINESS OWNER INFORMA nom CHEcKIF OWNER CURRENTLYONFiLEwtTHEHD❑ <br /> BUSINESS PHONE: <br /> OWNER'S NAME <br /> Flat Miji Last <br /> BUSINESS NAME(If different from Owner Name) SOC Sec orTax ID# <br /> OWNER'S HOME ADDRESS <br /> CIN STATE zip <br /> O NER'S MAILING ADDRESS (If different from Owner's Address) Attention orCare of <br /> Lo Z <br /> MAILING ADDRESS CIN I /��1 zip / 1 <br /> TYPE OF OWNERSHIP: <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY OTHER❑ <br /> FACILITY FILE <br /> FACILITYID#: C) ,LLf j CO-OWNER ID#: ACCOUNTID#: <br /> COMPLETFTHEFOLLOwlwBUSINESS FACILITY INFORMAT/ON: <br /> F',- <br /> hla a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES NO ❑ <br /> nahl_u his an E%ISTING Business LOCATION but a NEw TYPE of regulated Business? YES ❑ No ❑ <br /> BusiNr4FACILITY NAME(This will be the BuswEss NAmEon the HEALTH PERMIT) <br /> Q <br /> FAC 10 <br /> ADDR (If FAC/Llrris a Mosl EFooD UNtror FooH/CLEea the COMMISSARY ADDRESS) BUSINESS PHONE ' I <br /> 4 U 1l � <br /> 5 - � Suite# t/ <br /> CI (IfFACl/ITVIS a MOSILEF000 UNITOr FOOD VEHICLE use the COMMISSARY CIM STATE zip ' 1 <br /> CAq 52 �(9 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> MAILING DDRES fOFHealth Permit(If OIFFERENTfrom FacilityAddmss) Attention orCare Of <br /> MAILING ADDRESS CITYLLI STATE zip LA <br /> SIC CODE: APN#: COMMENT: �-{ <br /> ACCOUNTADDRESS for fees and charges: OWNER ❑ FACILITY/BUSINESS ❑ <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner, Operator,or Authorized Agent of this Business,and <br /> 1 acknowledge that all PERMIT FEES,PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation will be billed to me at the <br /> address identified above as the ACCOUNTAODREss for this site. I also certify that all information provided on this application is true and correct;and that <br /> all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or <br /> FEDERAL Laws and Regulations. <br /> APPLICANT'S NAME: SIGNATURE: <br /> Please Print <br /> TITLE: DATE DRIVER'S LICENSE# <br /> PHOTOCOPY REQUIRED <br /> Approved By Date Accounting Office Proceeeing Completed By � /j, Dam <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 LOCATION <br /> except UST Program(Use SWRCB forms) <br /> EHD 48-02-035 Masterfile Record-Green <br /> 8/19/08 <br />