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MaTmSAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ` MAY 11 2016 SHI �t 1jHflWLi y =OWNER Dfr ? ?q �E# PERMIT/SERVICE=S OWNER FILE CO10PLETETHE FOLLowINGBuSINESS OWNER IMFORMATION; CHEcKIF OWNER CURRENTLYONFILE W(rHEHD❑ BUSINESS OWNER'S NAME <) Q A PHONE: First Mf Last C, BUSINEss NAME(if different from Owner Name) oC 50C rTax ID# OWNER'S HOME ADDRESS '256(6 6L S CITY _�_o o t ST TA zip R 5 aya OWNER'S MAILING ADDRESS (If different from Owner's Address) Attention or Care of M MAILING ADDRESS CITY STATE ZIP TYPE OF OWNERSHIP; CORPORATION❑ INDIVIDUAL DQ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY OTHER❑ FACILITY FILE FACILITY ID#: 0 35 CO-OWNER ID#: ACCOUNT ID#: Moo COXPLETETHEFOLLOIRIINGBUSINESS FACILITY INFORMATION. Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES NO ❑ n....T..�.r� Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No BUSINEss/FACILITY NAME(This will be the BUSINESSNAmEDn the HEALTH PERMIT) S Q I`1 FACILITY ADDRESS(If FA=lrris a MOBILEF000 UNITor FOOD VEHICLEuse the COMMISSARY ADDRESS) BUSINESS PHONE 25GG 0ouGL0,S FkR OakQt Suite# aoQG -bots CITY(If FACILITYIS a MOBILE FOOD UNIT Or FOoD VEHICLE use the COMMISSARY CITY) STATE zip CA Rs BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 FMAILING ADDRESS for Health Perm%t(If OIFFERENTfrom Facility Address) Attention orCare Of MlRaig L0 u hl A MAILING ADDRESS CITY STATE ZIP SIC CODE: APN#: C4MMENT: ACCOUNT ADDRESS far 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 PERMITFEES,PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation will be billed to me at the address identified above as the ACCOUNTAIDDRESS 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. If APPLICANT'S NAME: L�J eairw% 0ou-60A SIGNATURE. ` Please Print TITLE: DATE DRIVER'S LICE SE# W PHOTOCOPY REQUIRED Approved By Date V 5 141 Aecaunt;ng Office Processing Completed By Date A PROGRAM{EHD 48-02-034 Pink)or WATER SYSTEM(EHD 46-02-003)form mast 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