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N JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MCENE10 <br /> MASTERFILE RECORD INFORMATION FORM <br /> OCT 0 6 2017 <br /> S14ADED SEC77ONS FOR EHD USE ONLY OWNER ID# CASE <br /> 'ENVIRONMENTAL HEALTH <br /> PERMIT/SERVICES OWNER FILE <br /> COMPLETE THEFOLLOWING BUSINESS OWNER INFORMATION.' CHECNIF OWNER CURRENTLYDNF1LEw1rHEHD13 <br /> BUSINESS r <br /> OWNER'S NAME - -t PHO/N�E: <br /> Fkst M! Last �V gQq 2146 <br /> BUST S NAME(If differentfro m0 er(dame) Soo Sec orTax ID# <br /> OWNER'S HOMEADDRESS 7je�L(fk <br /> CITY ZIP <br /> OWNER'S MAILING ADDRESS (If different\fromOwner s Address) Attention or Care of <br /> MAILING ADDRESS CITY PTAf]:Z:lp <br /> TYPE OF OWNERSHIP: <br /> CORPORATION❑ INDIVIDUALpi PARTNERSHIP❑ LoCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID#: CO-OWNER ID#: ACCOUNT ID#: <br /> COMPLETE THEFOLLOWING BUSINESS FACILITY INFORMA77ON. <br /> Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES ❑ No ❑ <br /> r%.0A br..Cw'9 <br /> Is this an ExrSTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ NO ❑ <br /> BUSINESS/FAC NAME(This will be the$usrNESSNAMEon the HEALTH PERMIT) <br /> FACILITY <br /> ,1 ADDRESSSS(IffFAcalrrYiiss a MoaxEF D UNlror FOOo VEH=Euse the COMMISSARY ADDRESS) �BUSINESS <br /> —U}(SI NEESSSSPHONE t� <br /> suite# �!v O� 2 L`(U <br /> CITY(If FACAI71'IS a MDE74EFOOD UNrror FOOD VEHJCLE use the COMMISSARY CITY} Zip <br /> nL <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> MAILING ADDRESS for Health Perm%f(If D/FFER1=N7-from Fac;fityAddressJ 7:::] Attention or CareOf <br /> MAILING ADDRESS CITY <br /> STATE ZIP <br /> SIC CCbe: ApN#; COMMENT: <br /> ACCOU T DO ESS for fees and charges: OWNER FACILITYIBUSINESS ❑ <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that[am the Owner, Operator,or Authorized Agent of this Business,and <br /> I acknowledge that all PERMIT FEES,PENAL77ES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation will be billed to me at the <br /> 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 <br /> all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Stand nd STATE and/or <br /> FEDERAL Laws and Regulations. /� _ <br /> APPLICANT'S NAMES�'vU �' Z ` <br /> SIGNAT <br /> O ` Please Print <br /> TITLE: 7V,�\1r`1J DATE --L DRIVER'S LICENSE# <br /> PHOTOCOPY REQUIRED <br /> Approved By Date Accounting Ofrics Proeesaing Completed By Date <br /> A PROGRAM{EHD 46-02-034 Pink)or WATER SYSTEM(EHD 46-02-003)form must be completed for each EHD regulated operation at this LOCATION <br /> except UST Program(Use SWRCB forms) <br /> END 48-02-035 <br /> 6!19108 Masterfile Record-Green <br /> I <br />