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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM SHADED SECTIONS FOR EHD USE ONLY OWNER ID# Dl�ooz� CASE# OWNER FILE COMPLETE THE FOLLOW/NG BUS I NESS OWNER/NFORMAT/ON.' CHECK/F OWNER CURRENTLY ON FILE wtTH EH D❑ BUSINESS jr,-, c; , sPHONE: OWNER'S NAME (!lat C �.� }� t� Firs( 1141 Last BUSINESS NAME(If different from Owner Name) Soc Sec or ax ID# � G c w u c civ 's S&yrr , OWNER'S HOME ADDRESS 9'3 p C L I<_ I t rLLS D aZ, CITYfSTA E ZIP S�l32 l 1�i '- l; OWNER'S MAILING ADDRESS (If different froinOwner's Address) Attention orCare of MAILING ADDRESS CITY STATE ZIP TYPE OF OWNERSHIP: CORPORATION INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY El COUNTY AGENCY U STATE AGENCY U FED AGENCY I_J OTHER IJ FACILITY FILE FACILITY ID#: :90 CO-OWNER ID#: ACCOUNT ID#: 6 COMPLETE THE FOLLOW/NG BUSINESS FACILITY INFORMATION: Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES Ef NO ❑ Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No BUSINESSIFACILITY NAME(This will be the Bus/NESsNANEon the HEALTH PERMIT) T� yo W S-I-Ru Cl-_re)w uy-iT r,. FACILITY ADDRESS(If FACILIrrls a MOBILEFOoo UNITor F000 VEHICLEUse the COMMISSARYAooREss) BUSINESS PHONE � r precon Streer Name Street- #top �14-228-y187 TATE ZIP CITY(If FACNTV is a MOOLE FOOD UMTor FOOD VEHICLE use the COMMISSARY CITY) S 74-x-f �: ;n lr� 915 ir2�' BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY] KEY2 MAILING ADDRESS fhrHea/th P0f711/f(If DIFFERENTfrom Facility Address) Attention orCare Of MAILING ADDRESS CITY STATE ZIP —A SIC CODE: APN CowuENr: ACCOUNTADDRESS for fees and charges: OWNER ❑ FACILITY/BUSINES ❑1Ir BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent oft is 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: J R l%,if' ] Ur,-T c✓ SIGNATURE: Please Print Q TITLE: S � + DATE 1 I Z I � DRIVER'S LICENSE# � PHOTOCOPY REQUIRED) U I [ApP- ed By Data Accounting Office Processing Completed By Date A PROGRAM (EHD -034 Pink)or WATER YsTEM(EHD 46-02-003)form must be completed for each EHD regulated operation at this LOCATION except UST Program( se SWRCB forms) EHD 48-02-035 Masterfile Record-Green 11/27/07