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SAN JOAaroIN COUNTY ENVIRONMENTAL HEALTH De ARTMENT MASTERFILE RECORD INFORMATION FORM SNADEDS6cnoNSFOREHDUSE0NLy OWNERID# CASE 1111. OWNER FILE COMPLETE THEFOLLOwtNG BUSINESS OWNER INFORMATION.- CHEctr iF OWNER CuRRENTL roRFmEw1m EHD❑ BUSINESS J QV i r 7 PHONE: OWNER'SNAME ZY3w _ SW Z r Firsf MI Lasf BUSINESS NAME(If diReranthomOw eme) Soc Sec orTax ID# ✓ Naitve va I ro 4�, V;76 - N -I)/ OWNER'S HOME ADDRESS p, CITY I. T E ZIP OWNER'S MAILING ADDRESS(If diKerentfrom Owners Address) Adention orCare of MAILING ADDRESS CITY STATE ZIP TYPE OF OWNERSHIP: CORPORATION❑ INDIVIDUAL 4 PARTNERSHIP El LOCAL AGENCY❑ COUNTYAGENCY❑ STATE AGENCY El FED AGENCY❑ OTHER❑ FACILITY FILE FAciuTYID#: CO-OWNER 11D#: ACCOUNTID#: r7 COMPLETE THEFOLLOW/NG BUSINESS FACILITY INFORMATION: IS this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES NO ❑ Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ NO A BUSINESS/FACILITY NAME(This will be the eu�NEss RAMEon the HEALTH PERMIT) n 1 I � FACILITY AO RESS(BFAC1VffIsa MDsl FOOD UN?or FDOD VENCLEuse the COMMISSARY ADDRESS I BUSINESS PHONE IVSD S (r�( t Suite# CITY(if FACII(f�/r��Yll,s a MOBILE FOOD UW or FOOD VEHICLE use the COMMISSARY CRY) STATE„ ZIP 1 K Cw BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 MAILING ADDRESS for Health Pernttt(If O/FFERENTfrom Fac/y/ityAddress) Attention OrCary Of r, 1 ( t` C ! MAILING ADDRESS CITY STATE Q ZIP SIC CODE: APN#: COMMENT: /r ACCOUNTADORESSforfees 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 1 acknowledge that all PERMIT FEES, PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation will be billed to me at the address identified above as the ACCouNTADDRESs 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: �Q I l ' SIGNATURE: W&I)L f7 P/ease Print TITLE: DATE / DRIVER'SLICE T PH'To COPYR Approved By AN /� A.,. � Date "7Accounting Office Processing Completed bate C�q /q A PROGRAM(EHD 4B-✓0/2"--0034 Pink)or WATER SYSTEM{EHD 48-02-003)form must be completed for as regulated operation at this LOCATION except UST Program(Use SWRCBforms) SAN JOAQUIN COUNTY EHD48-02-035 ENVIROMENTAL Masterfile Record-Green 11127107 HEALTH DEPARTMENT