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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM SHADED SECTIONS FOR EHD USE ONLY OW NER I D# v` wDOLIv�LAS CASE# OWNER FILE COMPLETE THE FOLLOw/NGBUSiNESS OWNER INFORMATION: CHECKIF OWNER CURRENTLroNF1LEw1THEHD❑ BUSINESS –r–Q �� PHONE: OWNER'S NAME First MI Last BUSINESS NAME(If different from Owner Name) SOe Sec Tax ID OWNER'S HOME ADDRESS CITY STLTTE ZIPR 5 �� OWNER'S MAILING ADDRESS (If dif/erentfrom Owner's Address) Attention orCare of `� Z$U(v MAILING ADDRESS CITY Z ^ - +� C ! ZIPqC TYPE OF OWNERSHIP: ,•—fv C� CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY OTHER❑ FACILITY FILE FACILITY ID#: �2 jU 7 CO-OWNER ID#: ACCOUNT ID#: COMPLETE THEFOLLOw/NGBUSINESS FACILITY INFORMAT/ON.' IS this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES NO ❑ Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ NO UZ B�,N_ESSS_/Fl cll_ITY NAME(This will be the BusnvEss NaMEon the HEALTH PERMIT) �—fV1 j^ FACILITY ADDRESS(If FACILITYis a MOBILEFODD UNn-or FFo�oo""D 1�VENICLEuse the COMMISSARY ADDRESS) BUSINESS PHONE U W• a�_\! ��—Z �. Suite —20q— 10 3--SKS Number Direction Street Name Street TyneCITY(If FACIL/TYIs a MOBILE FOOD UNIT Or FOOD VEHICLE use the COMMISSARY CITY) STATE ZIP �P0 0 C/� 9�S 3(�o I!p BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 MAILING ADDRESS for Health Perm/t(If DIFFERENTfrom Facility Address) Attention orCare Of MAILING ADDRESS CITY STATE ZIP C� I53v� SIC_CO-_- APN#: COMMENT: 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 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: C:7) FA SIGNATURE: Please Print / ``y'' TITLE: Q Lj��2 DATE ' j(( (� DRIVER'S LICENSE# 1 PHOTOCOPY REQUIRED)139 Approved By wur n Date ( ' Accounting Office Processing Completed By Date A PROGRAM{EHD 48-02-034 Pink}or WA ER 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 8/19/08