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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM SHADED SECTIONS FOR EHD USE ONLY �LOWNER I D_#:1 # �PJo0�357 CASE# OWNER FILE r COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION: CHECK IF OWNER CURRENTLYON FILE wITHEHD❑ BUSINESSPHONE: OWNER'S NAME l`(�✓l GIS G� a.Vn a-,> First MI Last �I -� u l 9 I BUSIN SS NAME(If different from Owner Name) Soc Sec orTax ID Cru ( 1't - OWNER'S HOME ADDRESS CITY -tSTP�E� ZIP OWNER'S MAILING ADDRESS (If different from Owner's Address) Attention or Care of C PC) (�0�_- lJ MAILING ADDRESS CITY ��C(/�(J v� S��E ZIP TYPE OF OWNERSHIP: l�� CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY OTHER❑ FACILITY FILE FACILITY ID#: -3 Z� CO-OWNER ID#: ACCOUNT ID#, Iw0 q-77: COMPLETE THEFOLLOWING BUSINESS FACILITY INFORMATION: Is this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES ❑ NOS 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) FACILITY ADDRESS(If FACILITYis a MOBILEFODD UN1TOr FooD VEHICLEuse the COMMISSARY ADDRESS) BUSINESS PHONE Suite# CITY(If FACwrYls a MOBILE fOOD UNIT Or FOOD VEHICLE Use the COMMISSARY CITY) STATE ZIP^ i Sfi Cc l_T S,Z BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 MING ADDRESS for Health Permit(If DIFFERENTfrom Facility Address) Attention orCare Of P. .) 1 MAILING DDRESS CITY ST ZIP SIC CODE: APN#: COMMENT: 7a.,ACCOUNTADDRESS for fees and charges: OWNER 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 and/Or HOURLY CHARGES associated with this operation will be billed to me at the address identified above as the ACCOUNT ADDRESS 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 and/or Standards and STATE and/or FEDERAL Laws and Reg ulatio - / APPLICANT'S NAME, ! ' SIGNATURE: Please Print TITLE: DATE DRIVER'S LICENSE# PHOTOCOPY REQUIRED Approved By Date Accounting Office Processing Completed By Date �3 A 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) EHD 48-02-035 Masterfile Record-Green 8119108