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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> SHADED SECTIONS FOREHD USE ONLY OWNERID # 0A)00aa q3 CASE # <br /> OWNER FILE <br /> COMPLETE THE FOLLOWING BUST NESS OWNER INFORMATION: CHECK lF OWNER CuaRENTL voN FILEWITH EHD❑ <br /> BUSINESS <br /> PHONE: <br /> OWNER'S NAME <br /> First MI Last <br /> BUSINESS NAME (If differentfrom Owner Name) Soo Seo orTax ID # <br /> f <br /> OWNER'S HOME ADDRESS Z30 5'0 2-4(t) <br /> CITY I \l �) t) - t re STATE ZIP /1 C <br /> OWNER'S MAILINGADDIRESS (If different from Owner's Address) Attention crCare of Y ✓ <br /> MAILING ADDRESS CITY STATE ZIP <br /> TYPE OF OWNERSHIP: <br /> CORPORATION INDIVIDUAL ❑ PARTNERSHIP ❑ LOCAL AGENCY ❑ COUNTY AGENCY ❑ STATE AGENCY ❑ FED AGENCY OTHER ❑ <br /> FACILITY FILE <br /> FACIUTYID #: Cba;1LaS3 CO-OWNERID #: ACCOUNTID #; Aippo S� ZD <br /> COMPLETE THEFOLLOW/NG BUST N ESS FACILITY INFORMATION: <br /> IS this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES ❑ NO ❑ <br /> n=oAo...0.M <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ❑ <br /> BUSINESSIFACILITY NAME (This will be the BUSINESS NAMEon the HEALTH PERMIT) <br /> J l� <br /> FACILITYADDRESS (If FAC/Llrrisa MOSrcEFOODUNiror Fypo VJEHICLEUg, the COMMISSARY ADDRESS) BUSINESS PHONE <br /> Com,,,+ Va ( l PO, C-I,+,J M u 5 (D„Al,1�t .IL- .,`r"J �( L <br /> StreetAlumberSuite # <br /> CITY (if FACILITY IS a MOBILE FOOD 9ymor FOOD VEHICLE USO the COMMISSARY CITY) STATE ZIP <br /> 1�11>`QU ) SLALA311 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> MAILING ADDRESS for Health Permit(If OIFFERENTfrom FaoilityAddress) Attention orcare Of <br /> MAILING ADDRESS CITY STATE ZIP <br /> SIC CODE: APN #: COMMENT: <br /> ACCOUNTADORESS forfees and charges: OWNER ❑ FACILITY/BUSINESS ❑ <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I, the undersigned Applicant, certify that I am the Owner, Operator, or Authorized Agent of this Business, and <br /> I acknowledge that all PERMIT FEES, PENALTIES, ENFORCEMENT CHARGES and/Or HOURLY CHARGES associated With this operation will be billed to me at the <br /> 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 <br /> all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or <br /> FEDERAL Laws and Regulations. <br /> APPLICANT'S NAME: SIGNATURE: <br /> Please Print <br /> TITLE: DATE DRIVER'S LICENSE # <br /> PHOTOCOPY REQUIRED <br /> Approved By Date Accounting Office Processing Completed By Date ' ^ <br /> 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 <br /> except UST Program (Use SWRCB forms) <br /> EHD 48-02-035 Masterfile Record -Green <br /> 8119/08 <br />