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0AIN ,3U,e,QUIN UOUNTY LNVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM SHADED SECTIONS FOR EHD USE ONLY OWNER I D# CASE# OWNER FILE COMPLETE TI-IEFOLLOWINGBUSINESS OWNER INFORMATION.' CHECKIF OWNER CURRENTLYONFiLEWITHEHD❑ BUSINESS OWNER'S NAME n ne � o Y-6 5 PHOc�NE: First MI Last 2t)/- L175-o- 9 Q BUSINESS NAME(If different from Owner Name) Soo Sec orTax ID# Sweef +Tecc'� 62271 13�y OWNER'S HOME ADDRESS Mg- C-0.y-CAW1o'vt 1 DY. CITY S-0 C YL STATS ZIP 9 OWNER'S MAILING ADDRESS (If different from Owner's Address) Attention or Care of 3225- La.Y-A yYLO VI� D f- [MAILING ADDRESS CITY S( ✓ G( L x ST�T,E ZIP Q -20 p TYPE OF OWNERSHIP: / r CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY OTHER❑ FACILITY FILE FACILITY ID#: CO-OWNER ID#: ACCOUNT ID#: CO!r1PLETETHEFOLLOwINGBUSINESS FACILITY INFORMATION.- Is NFORMATION.Is this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES ❑ NO ❑ Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ❑ BUSINESS/FACILITY NAME(This will be the BuswESSNAMEon the HEALTH PERMIT) Sweep -�reet,-j3 FACILITY ADDRESS(If FACILITYIS a MOBILEFOOD UNtror FOOD VEHICLEuse the COMMISSARY ADDRESS) BUSINESS PHONE C�tGt(Gv»cllf Ave. 4g7 4 Suite# 20 9 - Z 2 CITY(If FACILITY IS a MOBILE FOOD UN/Tor FOOD VEHICLE use the COMMISSARY CITY) STATE ZIP S-6 h 0 5- 2710 7 BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 MAILING ADDRESS for Health Permit(If DIFFERENTfrom Facility Address) Attention or Care Of A yi vi- -c 1-((R r MAILINGADgRES CITY STAZIP 95.2.0 q d'17 v\ C' A- SIC CODE: APN#: COMMENT: ACCOUNTADDITESS for fees and charges: OWNER ❑ FACILITY/BUSINESS ❑ 31LLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and acknowledge that all PERMIT FEES,PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this Operation will be billed t0 me at the Iddress identified above as the ACCOUNTADDRESS for this site. I also certify that all information provided on this application is true and correct;and that If regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or EDERAL Laws and Regulations. �j fu' APPLICANT'S NAME: V1 V1 i' 4-P- 1 l QYf-1 5 SIGNATURE: Please Print I ITLE: DATE 2 Z Z DRIVER'S LICENSE# - S670 0 w n C (� 11 PHOTOCOPY REQUIRED j Approved By \ Date J� �i ' Accounting Office Processing Completed By Date PROGRAM{EHD 48-02-03✓4 Pink}or WATER JS STEM{END 46-02-003}form must be completed for each EHD regulated operation at this LOCATION xcept UST Program(Use SWRCB forms) -ID 48-02-035 Masterfile Record-Green 19108