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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> SHADED SECTIONS FOR EHD USE ONLY OWNER ID# OW DD S CASE# <br /> OWNER FILE <br /> COMPLETE THEFOLLOw/NG BUSINESS OWNER INFORMATION: CHECK IF OWNER CURRENTL Yom FILE WYTNEHD❑ <br /> BUSINESS PHONE: <br /> OWNER'S NAME <br /> First MI Last <br /> BUSINESS NAME(If different from Owner Name) - Soc Sec orTax ID# <br /> OWNER'S HOME ADDRESS <br /> CITY ISTATE ZIP Cl_CO <br /> OWNER'S MAILING ADDRESS (if different from Owner's Address) Attention orCare of J✓ <br /> MAILING ADDRESS CITY STATE ZIP <br /> TYPE OF OWNERSHIP: <br /> CORPORATION❑ INDIVIDUAL-14 <br /> NDIVIDUAL PARTNERSHIP El LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY El FED AGENCY OTHER❑ <br /> FACILITY FILE <br /> FACIUTYID#: i2Q3 1 Z��_ I ACCOUNT ID#: PADogf ?- !D <br /> COMPLETE THEFOLLOw/NG BUSINESS FACILITY INFORMATION: <br /> Is this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES NO ❑ <br /> nesee...euro <br /> Is this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ NO ❑ <br /> BUSINESS/FACILITY NAME(This will be the BUSINESS NAMEOn the HEALTH PERMIT) <br /> i <br /> FACILITY ADDRESS(If FACIILITYl s a M,Ca_a eFOOD UNITor FDOD VfEHIcLEuse the COMMISSARY ADDRESS) BUSINESS PHONE <br /> St I �IZ3 wL�7 ` �J - Suite <br /> CITY(if FAaLryis a MOBILE FOOD Ummor FOOD VEHICLE use the COMMISSARY CITY) STATE ZIP <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEYS _J <br /> MAILING ADDRESS for Health Per?ltt(If DIFFERENTfrom Facility Address) Attention orCare Of <br /> MAILING ADDRESS CITY 2 STATE ZIP <br /> SIC CODE: APNM OSI it3D 4a /p COMMENT: <br /> ACCOUNTADDRESS for fees 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 DMe Acoounling Office Processing Completed By Data <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 /> 8119108 <br />