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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM SHADED SEC7IONSFOR EHD USE OALY OWNERID# CASE# OWNER FILE COMPLETE 7NEFOLLOW7NGBUSI NESS OWNER WFORMAnom CHECK/F OWNER CURRENrzrONFILEMMEHD❑ BUSINESS �, PHONE: OWNER'S NAME ao�( LfB -a9a3 Frrst MI Last BUSINESS NAME(if&rerentfiomowner Name) Soc Seo orTax ID# My KnnM<le-s 37 OWNER'S HOME ADDRESS 151 t ' oke-11.,-,vnne Ter DRv� C" LOdti STAj,; ZIP OWNER'S MAILING ADDRESS(if ditfermtfronowner's Address) Atter,U.n Care o MAILING ADDRESS CITY STATE ZIP TYPEOFOWNEReHIP: CORPORATION❑ INDIVIDUAL PARTNERSHIP El LOCALAGENm❑ COUNTYAGENCY❑ STATEAGENCY❑ FED AGENCY❑ OTH EFdM FACILITY FILE FACILITY ID#: Co-OWNER ID#: ACCOUNT ID#: COMPLE7,E7HEFOLLOw/NG BUSINESS FACILITY/NFORMAnom Is this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES 9 NO ❑ Is this an BASTING Business LOCATION buta NEwTYPE of regulated Business? YES ❑ No n �, BUSINESsfFACILrry NAME(This will be the Busas&;NANEon the HEALTH PERMIT) M Nc�n�' �lJ0 IG 1e5 FACILITY ADDRESS(If FA¢IurrisaMCe F000UNrrorFOODVEHi use the Coxxla wAmREssl BUSINESS PHONE 151 mol<elurnne „rer Drtve Suite# ADI CITY(if FAeurrls a MoaLEF000 UNRor F000 Yancteuse the COMML45ARY Cm 1 L` u 1 ( STATE CA zip III g 2�0 BOARD OF SUPERVISOR DISTRICT LOCATION CODE KKEEYI KE12 MAILING ADDRESS forHea/tb Pefmfi N D/FFERENITTon FwldyAddre ) Attention or-Card Of J��1 h'F_ LL� Snf11�� MAILING ADDRESS CITY $TATE ZIP SICCOM: APN#: Coxxa�T: AtiCt7UNTA0URESS for 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 PERM?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 Standards and STATE and/or FEDERAL Laws and Regulations. APPLICANT'S NAME: .,,,�Id-l\ , l , �QS, ISI ( SIGNATURE: Pease Print TITLE: O"n DATE ' -I / —' DRIVER'S LICENSE IV KSr75r7 PHOTOCOPY REQUIRED p APprov W Dafe / -/ Accourding Office Processing Completetl By Date A PROGRAM{EHD 48-02-034 Pink}or WATER SvsTEM{EHD 46-02-003)form must be completed for each EHD regula enation at this LOC t except UST Program(Use SWRCS forms) EHD48-02-035 11/27/07 Masterfile Record-Green