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SAN.JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM SHADED SECTIONS FOR EHD USE ONLY OWNER ID# a1�001//JZ/ _ CASE# OWNER FILE `P COMPLETE THEFOLLOWENG BUSINESS OWNER INFORMATION., CHECK/F OWNER CURRENTLYONFILEWITHEHD❑ BUSINESS �011� PHONE: OWNER'S NAME 6� 15 � BUSINESS NAME(If different from First MI Last l l Owner Name) SOc Sec orTax ID# OWNER'S HOME ADDRESS ' LcLne: CITY ST TE ZIP OWNER'S MAILING ADDRESS (If different from Owner's Address) Attention or Care of lil�- W . Paxd e e MAILING ADDRESS CITY � $TATE ZIP TYPE OF OWNERSHIP: �{ CORPORATION❑ INDIVIDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY OTHER❑ FACILITY FILE FACILITY ID#: MoD 2-3 CO.OWNERID#: ACCOUNT ID#: Al2,004.3LSS COMPLETE THEFOLLOWING B USI N ESS FACILITY INFORMATION: IS this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES j?rNO ❑ n�e.er..—" Is this an ExISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ NO 211, BUSINESS/FACILITY NAME(This will be the BuswEss NAMEon the HEALTH PERMIT) 5 E hGfIIS t�I UL ,T FACILITY ADDRESS(If FACILITYIs a MOBILE FOOD UNITor FOOD VEHICLEUSB the COMMISSARY ADDRESS) BUSINESS PHONE 17x41 (Zo t I (Z,c7L1 c)q©-6Sv�J Suite# CITY(if FAClurvls a MOWLE FOOD U%N'Dr FOOD VE11cLE USE the COtdMISSARYCIn' STATE ^ ZIP �Y C i BOARD OF SUPERVISOR DISTRICT 1 LOCATION CODE , `, ` KEY/ KEY2 MAILING ADDRESS foi-Health Permitif D/FFERENTfrom Facility Address) Attention or Care Of W - n r 1-c ne MAILING ADDRESS CITY `7ko Ckc�fl STATE r. ^-� ZIP CA j 0— SIC CODE: APN#: I [ COMMENT: tJf ACCOUNTADDRESSfor fees and charges: OWNER ❑ FACILITY/BUSINESS RAI 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 t0 me at the address identified above as the ACCOUNTADDRESS 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 Regulations. APPLICANT'S NAME: SIGNATURE: Please Print TITLE: DATE DRIVER'S LICENSE# PHOTOCOPY REQUIRED) 1 Approved By Date 7� Accounting Offiae Processing Completed By Q+ Dew C �3 //I 1- I)v 11 A PROGRAM(EHD 48-02-034 Pink)or WATER/SYSTEM{EHD 46-02.003)form must be completed for each EHD regulated operationatthisLOCATION except UST Program(Use SWRCB forms) EHO 48-02-035 Masterfile Record-Green 8119108