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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM SHADED SECTIONS FOR EMD USE ONLY OWNER ID# D 6)0 j g CASE# OWNER FILE �f COMPLETE THEFOLLOWING BUSINESS OWNER AfFORMAT/ON.' CHECKIF OWNER CURRENTLYON FILE w1THEHD❑ BUSINESS PHONE: OWNER'S NAME The Habit Restaurants, 4C. First nar Les( (949) 851-8881 BUSINESS NAME(If different from Owner Name) Soo Sec or ax ID# The Habit Burger Grill #250 _ _ 26-0501 OWNER'S HOME ADDRESS 17320 Red Hill Ave, #140 CITY Irvine STCA zip 92614 OWNER'S MAILING ADDRESS (If different from Owner's Address) Attention or Care of Accounts Payable MAILING ADDRESS CITY $TATE ZIP TYPE OF OWNERSHIP: CORPORATION® INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY OTHER❑ FACILITY FILE FACILITY ID#: ,Z. �3 CO-OWNER I D#: ACCOUNT ID#: j 67 COMPLETETHEFOLLOW/NG BUSINESS FACILITY INFORMATION: IS this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES ® No ❑ rlcon oruc�rr0 Is this an EXISTING Business LocATtoN but a NEW TYPE of regulated Business? YES ❑ No BUSINESS/FACILITY NAME(This will be the BuswEss NAMEon the HEALTH PERMIT) The Habit Burger Grill #250 FACILITY ADDRESS(if FAC/LITYIS a MOBILE FOOD UNtror FOOD VEH/CLE Use the COMMISSARY ADDRESS) BUSINESS PHONE 1325 E. Yosemite Ave. Suite tt CITY(If FACiLITYis a MOBILE FOOD UNIT or FOOD VEHICLE use the COM isSARY CITY) STATE ZIP Manteca CA 95337 BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 MAILING ADDRESS for Health Permit(If DIFFERENTfrom Facility Address) Attention or Care Of 17320 Red Hill Ave. #140 Accounts Payable MAILING ADDRESS CITY Irvine STATE, ZIP 92614 SIC CODE: 5812 APN#: COMMENT; ACCO NTADDRESS for fees and charges: OWN X❑ 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 PERMIT FEES,PENALTIES,ENFORCEMENT CHARGES andlor 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 andlor Standards and STATE and/or FEDERAL Laws and Regulations. APPLICANT'S NAME: Matt Clark SIGNATURE: Please Print TITLE: Agent for owner DATE 10/2/18 DRIVER'S LICENSE# B3368455 PHOTOCOPY REQUIRED Approved By 7 .-te e Proceaaing Completed By Date - L.2- Ilk 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) -HD 48-02-035 Masterfile Record-Green 3119/08