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0 0 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> SHADED SECTIONS FOR EHD USE ONLY OWNER ID# CASE# <br /> OWNER FILE <br /> COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION: CHECKIF OWNER CURRENTLY ON FILE WITH EHD <br /> BUSINESS �U/_ C/-lwG, PHONE <br /> OWNER NAME First Ml Last <br /> BUSINESS NAME(if d of homOwner Name) Sue Sec Or Tax ID# <br /> ar <br /> OWNER HOME ADDRESS <br /> CIN Z - Y'` ST zJP <br /> OWNER AILING DR (Ifdtillerenthom Oww Ad Attention orCa,e of_� <br /> Y lV/ ��Pq <br /> r'F'CC-e4 <br /> MAILING ADDRESS CIN r-/ ST TE Z1Pd�j <br /> TYPE OF OWNERSHIP: l !G <br /> - -CtSRPiS73A'rIDINOMDQAL PARTNERSHIP- COLAL AGENCY--COONTI AGENCY —$TATEAGENC{'-QED AGENCV OTHER <br /> FACILITY FILE <br /> FACILITY ID#: CO-OWNER ID#: ACCOUNT ID#: <br /> COMPLETE THE FOLLOWING BUSINEW FACILITY INFORMATION: <br /> -19 <br /> IS this a NEW Business LOCATION Or VEHICLE not preVI0U51y regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO <br /> Is this an EwsTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No <br /> BUSINESSIFACILIN NAME(This will be the BustnEssNAmEon the HEALTH PERMIT) <br /> FACILITY ADDRESS pF Adue rr is a MoBiLEF000 UNrrorFOOD Ventuse the L2ti.issww AnnaFss,� r USINESS PHONE �J <br /> J16—03S--';—C/ /G S—C 13—ti <br /> ae# <br /> CITYpfFArynYls oeae FOOD llwror F000,VErfrcLEuse the Gnuwgs yrv) STA zip _1 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEYT KEY2 <br /> MAILING ADDRESS for Heaiflt Pe it(H /FFEREN from FadlityAddress) Attention or Care Of <br /> '590W <br /> �! h <br /> MAILING ADDRESS <br /> lCITY SATE p <br /> SIC CODE: APN#:! 6 QS ��'' CornaExr. VdCG.-� <br /> ACCt]IIMLADDRPCB for fees and charges: OWNER FACILITI1BUSINES5 ❑ <br /> Srrx.TNG AN^D C'nn i,YANcr Acrcnnw ennnwevT: 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,PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation will be <br /> billed to me at the address identified above as the ACCOUNT ADDRE,cs for this site. I also certify that all information provided"s application is true <br /> and correct; and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordih nee Codes and/or <br /> Standards and STATE and/or FEDERAL Laxs.and Rc ulations. <br /> APPLICANT NAME: X- re'), 'FglJ SIGNATURE: <br /> ease dnt <br /> TITLE; '2 d ��' DATES �� 01 DRIVER'S LICENSE#PHOTOCOPY , <br /> Approved By Date Accounting Office Processing Completed By Date <br /> A PROGRAM(EHD 46-02-034 Pink)or WATER SYSTEM(EHD 46-02-003)form must be completed for each EHD regulated operation at this LOCATION except <br /> UST Program(Use SWRCS forms) <br /> EHD 48-02-035 Masterfile Record-Green <br /> '10/9/2003 <br /> J <br />