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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT RECENEDMASTERFILE RECORD INFORMATION FORM OCT 0 6 2017 SHADED SEcuoNS FOR END USE ONLYOWNER ID# � �7 J '.Z CASE# ENVIRONMENTAL HEALTH (ate PERMITISERVICES OWNER FILE COMPLETE THEFOLLOWINGBUSINESS OWNER INFORMATION.' CHECKIF OWNER CURRENTLYONFILEwiTHEHD❑ BUSINESS PHONE: OWNER'S NAME IV Q � A-1`l First Ml Last BusiNASS NAME(if tfrom o er e) Soc Se rTi x ID# OWNER'S HOME ADDRESS CITY �G� T E ZIP OWNERS MAILING ADDRESS (If different from Owner's Address) Attention or Care of ` �V 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 IE#: �� COMPLETE THEFOLLOWINGBUSINESS 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/FAC NAME IT is will be the gUSINESSNAMEon the HEALTH PERMIT) t� l FACILITY ADDRESS(If FAClLIMS� a MOBILE F D UNITor FOOD VEHICLELSS the COMMISSARY ADDRESS) BUSINESS PHONE { , � ► u-V I�tStreet rime suite# CITY(If FACILITY Is a MOBILE FOOD UNIT or FOOD VEHICLE use the COMMISSARY CITY/ I T ZIP BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEYS KEY2 MAILING ADDRESS for Health Permlt(lf DIFFERENTfrom Facility Address) Attention or Care Of MAILING ADDRESS CITY STATE zIP SIC CODE; APN# COMMENT: ACOUNTAODRESS for fees and charges: OWNER FAGILITYI$USINESS ❑ BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,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 and/or HOURLY CHARGES associated with this operation will be billed to me at the address identified above as the ACCOUNTADORESs 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 Stand nd STATE and/or FEDERAL Laws and Regulations. _ APPLICANTS NAME- C kole SIGNAT Please Print TITLE: 0 �� DATE 0.-0--1 - PHIVER'S LICENSE# OTOCOPY REQUIRED Approved By pate Accountlng Office Proceaaing Completed By pate 111311 / 3 / 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 48-02-036 Masterfile Record-Green 8119106