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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM SHADED SECIMNS FOR E14D USE ONLY OWNER ID# � �i�15 75- CASE# OWNER FILE COMPLETE THE FOLLOwlNGBUSINESS OWNER INFORMATION. CHEONlF OWNER CURRENTt-YONF14EwiTHEHD❑ BUSINESS Y-irr C S ) PHONE: L13 OWNER'S NAME �` r r►� ZO"J- Zoc� -• Z3 Z 3 First Mf Last BUSINESS NAME(if diferentfromowner Name) SOc Sec rTax iD# Sf lrm )Q4mI /"G `1 - OWNER'S HOME ADDRESS �Z�a SZ E /i�� Zu 1 Z q CITY �bL kG �CarE WE ZIP 6?62-3 ntion orCare of OWNER'S MAILING ADDRESS (If different from Owner's Address) Atte MAILING ADDRESS CITY STATE zip TYPE OF OWNERSHIP: CORPORATION 0 INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY OTHER❑ FACILITY FILE FACILITY ID#: �2,,3 O CO-OWNER ID#: ACCOUNT ID#: COMPLETE THEFOLLOw/NGBUSINESS FACILITY INFORMATION: is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES ® NO ❑ r%.........1t0 Is this an ExISTING Business LOCATION but a NEW TYPE of regulated Business? YES M No ❑ BUSINESSIFACILITY NA�''IjIE(This will be the BUSINESS NAME the HEALTH P IT) -N 1rm Ft*M 11 In L FACILITY ADDRESS(If FACIUrYIs a MOSILE FOOD UNITer FOOD VEHICLEUSe he COMMISSARY ADDRESS) BUSINESS PHONE 1&00 L.V4.S-r C.�aAe_ LI _ SDife# v2d(�-r ` -a �C "!/��j / CITY(If FACILITYIS a MOBILE FOOD UNIT Or FOOD VEHICLE use the COMMISSARY CITY) STATE ZIP Loc�i c t� 75zg2_ BOARD OF SUPERVISOR DISTRICT` LOCATION CODE KEY1 KEY2 MAILING ADDRESS for Health Permit(If DIFFERENTfrom FacifrtyAddress) Attention orCere Of 12357— E 9 "4 !Z r C 3 MAILING ADDRESS CITY LTV ( STATE ZIP SIC CODE: APN#: COMMENT: ACCDUNTADDRE$$for fees and charges: OWN 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,ENFORCJ=MENT CHARGES and/or HOURLY CHARGE$associated With this Operation will be billed tome 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 alt applicable SAN JOAQUIN COUNTY Ordinance Codes and/or tandards and STATE and/or FEDERAL Laws and Regulations. APPLICANTS NAME: 8 +^ 7 1✓Yrl SIGNATURE: ` TITLE: Please Print DATE I f Q JZO I ] } 73� CAI DRIVER'S LICENSE# PHOTOCOPY rREQUIRED) Approved Date _J'� Accounting Office Processing Completed By Date I A PROGRAM(EHD 48-02-034 Pink)or WATER SYSTEM(EHD 46-02-0031 form must be completed for each EHD regulated operation at this LOCATION except UST Program(Use SWRCB forms) EHD 48-02-035 Masterfile Record-Green 8119108