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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM SHADED SECTIONS mREHD USE ONLY OWNER ID# B�DU2,.ZG�L CASE# OWNER FILE COMPLETE THEFOLLOW/NGSUSINESS OWNER/NFORMAT/ON.' CHECKIF OW NER CuRRENrzYoNF&E w THEHD❑ BUSINESS ��t► IrIG{Shn ►CIG PHONE: owNER'SNAME Ny M/ test aoq 4ga -a9a3 BUSINESS NAME(if&ff&n nffromOwner Name) • Tax IV a My K4,A0L':5ok►es OWNER'S HO1M5m E ADDRESS 1j oI<e It&mne � Ive(- Dflv�, CITY Lo„t 1 STA , ZIP 952** OWNER'S MAILING ADDRESS(If di9erantfiwnOwner's Address) Attention orCare of �u,�,l A . RSI+nIt) MAILING ADDRESS CITY STATE ZIP TYPEor OwNsuxvP: CORPORATION[I INDIVIDUAbFdf PARTNERSHIP El LOCALAGENCY❑ COUNTY AGENCY El STATE AGENCY El FED AGENCY[I OTH FACILITY FILE FACluTYID#: �'� 2j CO-OWNERID#: ACCOUNTID#: ComnErE 7NEFotcowfNG BUSINESS FACILITY lwoRMA77ow [1,1'sIhIS a NEW Business LOCATIONOrVEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YESgNothis an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No BUSINESS/FACIUTY NAME(This will be the 6usrwEssAkiiww the HEALTH PERMIT) My NCoo kIeS FACILITY ADDRESS(NFAracnris a Moa&EF000 UMror FDoo✓€Hicceuse the CoMrlssamAMREss) BUSINESS PHONE I51 Moke4tmne R%ver Ortve suite III CITY(if FAuI Is a Moan FooD UMTor FooD VEHIctE use the CoaaisswY OW Lo 1 • STATE CA ZIP ��2-�Q ( BOARD OF SUPERVISOR DISTRICT ] LOCATION KEY1 KEY2 MAILING ADDRESS for HeaIH1 PefRHt(N D/FFEREVTfrom FscilftyAocDess/ Aftntion orCard Of 7t.t,lt A,- Lt�t5�t1IC�� MAILING ADDRESS CITY STATE ZIP ¶u SIC CooE:_. _._ APN#: Coar,IENr: ACO MNTADDRESS for fees and charges: OWNER FACILITY/BUSINESS ❑ 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 t0 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. APPLICANT'S NAME: �./�.1 t 1 L . V,S, 1 n I l./I SIGNATURE: ✓W�+� V-' Pfease Print ��ttt TITLE: O DATE I a-I G /7 DRIVER'S LICENSE '3r7 —r7 r7 h 1 I PHOTOCOPY REQUIRED VV J Approv Date 1� / I Accounting Office Processing Completed By fn dam' A PROGRAM(EHD 48.02-034 Pink)or WATER SYSTEM{EHD 46-02-003)form must be completed for each EHD regula at this L except UST Program(Use SWRCB forms) EHD 48-02-035 Masterfile Record-Green 11/27107 C---_