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w SAN JOA UIN COUNTY ENVIRONMENTAL HEALTH AMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> SHADED SECTIONS FOR EHD USE ONLY OWNER ID It © W U O \ 5s3 \ CASE# <br /> OWNER FILE <br /> COMPLETE THE FOLLOWING BUSINESS OWNER INFOFAATION: CHECK IF OWNER CURRENTLY ON FILE WITH EHD <br /> BUSINESS tq—ur— PHONE <br /> OWNER NAME First MI Last <br /> BUSINESS NAME(Ifnt aorn Owner Name) Sue Seo orT <br /> OWNER HOME ADDRESS <br /> CITY 44MMIIC jjj1TY )S- La�hro Sr BP f 23 <br /> jonrm�r <br /> Aae Or Care of <br /> 3 WTOW I r c"�r' <br /> MAILING ADDRESS CITY ST TE LPC/ <br /> ry <br /> TYPE OF OWNERSHIP: <br /> CORPORATIO INDIVIDUAL El PARTNERSHIP El LOCAL AGENCY El COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY 11 OTHER El <br /> FACILITY FILE <br /> FACILITY ID#: CO-OWNER ID#: ACCOUNT ID#: <br /> COMPLETE THE FOLLOWING BUSINESS FACILITY INFORMATION: <br /> Is this a NEW Business LOCATION Or VEHICLE nOt PreVIOUSly regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NOX <br /> Is this an EXISTING Business LOCAnON but a NEW TYPE of regulated Business? YES ❑ No <br /> BUSINESSfFACIUTY NAME(This will be the BuswEss NAuson the HEALTH PERMIT) <br /> FACILITY ADDRESS(if gt,avis a Mowf FooD UN7crFOOD VEHIDLE use the COMMssh V AUMEM USINESS PHONE <br /> iq6-035-601148-oi3-iy <br /> r <br /> CrrYpfFa�^'rs oaaeFOODUMTorFOODVee0lEusetherommISSARYC11) STA LP_ <br /> .LG./i+'r lti <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEV1 KEV2 <br /> MAI LING AD DRESS r I'IfBIfII Pe If(8 FFE:REN from FadlilyAdmss) AttentionorCare Of <br /> MAILING ADDRESS CITY ATE ZIP <br /> 2 <br /> SIC CODE: APN#:! 6 Q' COMMENT. V.:2CC�.T _� <br /> AccouNT AyDnEss for fees and charges: OWNER FACILITY/BUSINESS ❑ <br /> Bn I iNG ANn f'nMYI LANrY ACKNOVAFDCMrNT: I, the undersigned Applicant, certify that I am the Owner, Operator, or Authorized Agent of this <br /> Business,and I acknowledge that all PERMIT FEES,PEMLims,ENPORCEMER CHARGES and/or HOURLY CHARGES emaciated with this operation will be <br /> billed to me at the address identified above as the ACCOUNTADDReev for this site. I also certify that all information provided o is application is true <br /> and correct; and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordin nce Codes and/or <br /> Standards and STATE and/or FEDERAL.L and R ulations. <br /> APPLICANT NAME: 'r- CL J SIGNATURE' <br /> TITLE: Q �� DATEh1Q DRIVER'S LICENSE# <br /> (PHOTOCOPY REQUIREDt <br /> Approved By Date Accounting Office Processing Completed By Date lt\ 4y <br /> A PROGRAM(EHD 48-02-034 Pink)or WATER SYSTEM(EHD 46-02-003)form muat be completed for each EHD regulated operation at this I 6CATON except <br /> UST Program(Use SWRCB forms) <br /> EHD 48-02-035 Masterfile Record-Green <br /> 1019/2003 0 <br /> 0 <br />