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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM SHADEASEC77ONSFOR ENDUSE ONLY OWNER ID# (� CASE# OWNER FILE COMPLETE THEFOLLOWING BUSINESS OWNER INFORMATION: CyECK1F OWNER CuR►tENrtyolvF�tEwirHEHD❑ BUSINESS PHONE: OWNER'S NAME11 First M! Last BUSINESS NAME(If afferent from Owner Name) oc S _ orTax ID# OWNER'S HOME ADDRESS fle.S ,bf t . CITY l.�G t/ nAATE I ZIP OWNER'S MAILING ADDRESS (If different from Owner's Address) Attention or Care of C 1-�a 41,9w / /a CQ n MAILING ADDRESS CITY STATE ZIP TYPE OF OWNERSHIP: CORPORATION❑ INDIVIDUAL[j PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY OTHER❑ FACILITY FILE FACILITY ID#: $ GO-OWNER ID#: ACCOUNT ID; COMPLETE THEFOLLOWING BUSINESS FACILITY INFORMATION.- Is NFORMATION:Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES lel NO r%..ger.—m-7 1 Is this an ExISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ NO BUSINESS/FACILITY NAME(T is will be the BusrNEssNANF*n the HEALTH PERMIT) O I S FACILITY ADDRESS(If FACILIr4s 8 MORILEFOOD UNITor FOOD VEHICLEUSS the COMMISSARY ADDRESS) BUSINESS PHONE 55�2Q, Go5Grm6eS 40r- Suite# CITY(If FACILrY IS a MOBILE FOOD UNIT or FOOD VEHxLE use the COMMISSARY CI TY1 STATE zip BOARD OF SUPERVISOR DISTRICT^ LOCATION CODE KEY1 7KEY2 MAILING ADDRESS for Health Permlt(If DIFFERENTfrorn FaadityAddress) Attention orCars Of CP G�I�C MAILING ADDRESS CITY STATE ZIP IJ SIC CODE: APN#: COMMENT: ACCOUNTADDRE55 for fees and charges: OWN R 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, PENALrms,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. APPLICANTS NAME: // .SIGNATURE: lease Print TITLE: OATS DRIVER'S LICENSE# Q -76 / PHOTOCOPY REQUIRED O Approved By Data 4/ Accounting Office Processing Completed By Date a 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 8119!08