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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM SHADED SECTIONS FOR EHD USE ONLY OWNER ID# /} Q�Z ��j CASE# OWNER FILE COMPLETE THE FOLL Ow/NG BUS I NESS OW N ER/NFORMA now CHECK/F OWNER CURRENTLY ON FILE w/TH EH D❑ BUSINESS SPHONE: JY�_cY OWNER'S NAME W First h4/ Last BUSINESS NAME(If different from Owner Name) Soc Sec or ax ID# ' OWNER'S HOME ADDRESS q'3 C) CLI,_ H tj_L_S D,2, CITY 14 L-r SQA E ZIP S L!3Z OWNER'S MAILING ADDRESS (If different from Owner's Address) Attention orCare of MAILING ADDRESS CITY STATE zip TYPE OF OWNERSHIP: CORPORATION INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY U COUNTY AGENCY IJ STATE AGENCY LJ FED AGENCY El OTHER U FACILITY FILE FACILITY ID#: ( 5 CO-OWNER ID#: ACCOUNT ID#: b COMPLETETHEFOLLOW/NG BUSINESS FACILITY/NFORMAT/ON: 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'] BUSINESS/FACILITY NAME(This will be the BUSINESSNANEOn the HEALTH PERMIT) T 0 W S-rR."ur7,w t pl�c Z FACILITY ADDREBs(If FACILI7Yls a MOHILEFOOD UN1Tor FOOD VEHICLEUSe the COMMISSARY ADDRESS I BUSINESS PHONE - R2op �jlc�-228-y187 CITY(IfFAciuTVlsaMaaLEF000UuTorFooDWHrcLEuse the CommissARYCi L",07STATE ZIPS BOARD OF SUPERVISOR DISTRICT LOCATION CODE ]:KEY1 Kr,12 MAILING ADDRESS for HOa/th POfMit(If DIFFERENTfrom Facility Address) Attention orCare Of MAILING ADDRESS CITY STATE zip SIC CODE: APNft: CoMMENr: ACCOUNTADDRESS for fees and charges: OWNER ❑ FACILITY/BUSINES 1[7� BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of 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. J r FAPPLICANT'S NAME: J A ]oo SIGNATURE: Please Print TITLE: � DATE � DRIVER'S LICENSE# -, Ly's ( C"l-f" I I PHOTOCOPY REQUIRED) 1� I Approved By - - Date 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