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SAN JOAQUIN COUNT*PUBLIC HEALTH SERVICES • ENVIRON0TAL HEALTH DIVISION <br /> DATE �U ' `�'�6 MASTERFILE RECORD INFORMATION FORM (EH 0015(REVISED IO/02196) <br /> SHADED SECTIONS FOR EHDUSEONLY OWNER:ID# ` EASE# <br /> ......... <br /> OWNER FILE <br /> COMPLETETHE FOL L0WING BUSINESS OWNER /NFORMAT/ON. CHECKIF OWNER CURRENTLYONFILEWITHEHD <br /> ...................................................................... <br /> ...................................................................... <br /> BUSINESS OWNER PHONE <br /> NAME _________________—_ <br /> ...................................................................First <br /> .......................................!L1(..................................----........Last <br /> ......................................' SOC SEC/TAX ID# <br /> BUSINESS NAME(If different fro/ Owner Name) Il�1 <br /> UAI�O ►ttl iC- <br /> I <br /> OWNER HOME ADDRESS DRIVER'S LICENSE# <br /> l yll Dod S Zm 13a <br /> city <br /> STATE ZIP a�l <br /> OWNER MAILING ADDRESS IfD/FFERENTfrom OwnerAddress ! Attention:or Care of(opBonaQ <br /> Mailing Address City State i Zip <br /> TYPE OF OWNERSHIP: <br /> CORPORATION Ix INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID# I:... CROSS REF:ID# ACCOUNT ID# <br /> COMPLETETHEFOLLOW/NG BUSINESS FACILITY INFORMATION., <br /> Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DIVISION? YES ❑ NO ❑ <br /> Is this an EXISTING Business LocATION but a NEW TYPE of regulated Business? YES ❑ NO ❑ <br /> BUSINESS/FACILITY N ME(THIS WILL BE THE NAME ON H LTH P RMIT) <br /> rl <br /> FACILITY /ADDRESS fACIUTY/SA MOB/LE FOOD UMTOR FOOD LE USECOMMISSARY ADOREW '• SUITE# BUSINESS PHONE <br /> ? � ,k <br /> CITY IFFACILITYISAMOB/LEFoODUNITORFOODVEHICLEUSE Co ISSARYADDRESSCITY) STATE ZIP <br /> fjC <br /> :BOARD OF !UPERVISORDISTRICT :LOCATION CODE ii )(Eyi;: <I(Ey.� -<,:. <br /> i Mailing Address for Health Permit /fD/FFERENTfrom Faci/ityAddress i Attention:or Care Of(op8iona/) <br /> Mailing Address City STATE i ZIP <br /> SIC CODE APN# COMMENT <br /> THIRD PARTY BILLINGINFORMATION: Complete if Billing Party is different from Business Owner identirfed above. <br /> .................................................................... .................................................................... <br /> BUSINESS NAME ; Attention:or Care Of (optional) <br /> Mailing Address 1 i PHONE <br /> / f?W /A �9d Me r 'y 5-7Su���e 6 Z y/s�- Fez 6' <br /> CITY STAT ZIP <br /> r0. <br /> �+�, F � c;s c o t � 7 <br /> AC 'UUNTADDRESS for fees and charges OWNER ❑ FACILITY/BUSINESS ❑ THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE AcmNOWLEDGINIENT: I, the undersigned Applicant, certify that I am the Owner, Operator, or AuthoriZed <br /> Agent of this Business, and I acknowledge that all PERMIT FEES, PENALTIES, ENFORCEA]ENT CHARGES and/or HOURLY CHARGES <br /> associated with this operation will be billed to me at the address identified above as the ACCOUNTADDRESS for this site. I also certify <br /> that all information provided on this application is true and correct; and that all regulated activities will be performed in <br /> accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or FEDERAL Laws and <br /> Regulations. <br /> PLEASE PRINT <br /> APPLICANT NAME / J w� 1 � ' � n; � G I I ` SIGNATURE <br /> TITLE DRIVER'S LICENSE# <br /> /1 , ( G eo/O .S� PHOTOCOPY REQUIRED <br /> Approved By pate> Accounting Office Processing Completed$y J' Date,. <br />