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SAN JOAN COUNTY ENVIRONMENTAL HEALTH PARTMENT 6IASTERFILE RECORD INFORMATION F SHADED SECTIONS FOR EHD USE ONLY OWNER ID# U W (2 (Dalt�rr1 CASE# OWNER FILE COMPLETE THEFOLLOwING BUSINESS OWNER INFORMATION: CHECK IF OWNER CURRENTL YON FILE wiTH EH D❑ BUSINESS u K to f < PHONE: OWNER'S NAME Firs! M/ Last BUSINESS NAME(If di rent homOwner Neme) Soc SBC or Te%ID# OWNER'S WOME ADDRESS jeo if, CITY � STATE ZIP OWNER'S MAILING ADDRESS (If different from owner's Address) Attention orCare of MAILING ADDRESS CITY STATE 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 NAxEon the HEALTH PERMIT) FACILITY pADD'1RESS( FACILITYis a Mos&EFwc,UNITor FOOD VEHICLEUSS the COMMISSARY ADDRESS) BUSNESS PHONE - o5 is N 4) Suite# q�� Y'l9- y3D5 CITY(if FAAuLn-ris a BILE FOOD UNIT or FOOD VEHICLE use the COMMISSARY CITY) STATE zip BOARD OF SUPERVISOR DISTRICT 'I LOCATION CODE 1q KEY1 KEY2 MAILING DDRESS for Health ParMit(lf DIFFERENTfrom Facility Address) Attention or Care Of MAILING ADDRESSCITY I :, - STATE SIA ZIP :4 x--i [SIC APN#: tin V/nlykAi /l COMMENT: ACCOUNT ADDRESS for fees and charges: t t 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 acknowledge that all PERMIT FEES,PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation Will be billed tome 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 AccounEng Office Procevain#Completed By i Date 1_I� Il / A PROGRAM{EHD 48-02-034 Pink)or WATER SYSTEM{EHD 46-02-003}form must be completed for each EHD regulated operation at thi§LOCATION except UST Program(Use SWRCB forms) EHD48-02-035 Masterfile Record-Green 8/19/08