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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ASTERFILE RECORD INFORMATION F _ __ A SHADED SECTIONS FOR EHD USE ONLY LLOWNER ID# CASE# OWNER FILE COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION: CHECK IF OWNER CURRENTLY ON FILE wITHEHD❑ BUSINESS PHONE: OWNER'S NAME First Ml Last BUSINESS NAME(If different from Owner Name) Soc Sec or Tax ID# OWNER'S HOME ADDRESS CITY STATE zip OWNER'S MAILING ADDRESS (If different from Owner's Address) Attention or Care of MAILING ADDRESS CITY ESTATE zip TYPE OF OWNERSHIP: CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY OTHER❑ FACILITY FILE FACILITY ID#: CO-OWNER ID#: ACCOUNT ID#: COMPLETE THE FOLLOWING BUSINESS FACILITY INFORMATION: 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 ❑ BUSINESS/FACILITY NAME(This will be the BUSINESS NAMEon the HEALTH PERMIT) FACILITY ADDRESS(If FACILITY is a MOBILEFOOo UNITor F000 VEHICLE use the COMMISSARY ADDRESS) BUSINESS PHONE Street Number Direction Street Name Street Tyne Suite# CITY(If FACILITY is a MOBILE FOOD UNIT Or FOOD VEHICLE use the COMMISSARY CITY) STATE zip BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 7 KEY2 MAILING ADDRESS for Health Permit(If DIFFERENTfrom Facility Address) Attention or Care Of MAILING ADDRESS CITY JSTATE ZilP =SICCOD-. APN#: COMMENT: ACCOUNTADDRESS for fees and charges: OWNER ❑ FACILITY/BUSINESS ❑ BILLING AND COMPLIANCE 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,PENALTIES,ENFORCEMENT CHARGES andlor 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 FEDERAL Laws and Regulations. APPLICANT'S NAME: SIGNATURE: Please Print TITLE: DATE DRIVER'S LICENSE# PHOTOCOPY REQUIRED Approved By Date Accounting Office Processing Completed By Date 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 except UST Program(Use SWRCB forms) EHD 48-02-035 Masterfile Record-Green 8/19/08