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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM SHADED SECTIONS FOR EHD USE ONLY OWNER ID# CASE# OWNER FILE COMPLETETHEFOLLOW/NG BUSINESS OWNER INFORMATION: CHECKIF OWNER CURRENTLYONF/LEW/THEHD❑ BUSINESS *Z��r d PHONE: OWNER'S NAME / 1 Firss 1 t MI Last Owner Name) Soo Se orTax ID# OWNER'S HOME ADDRESS O Y // D ![ferl 3' 4'e- CITY L ST/gT ZIP C5 3 310 OWNER'S MAILING ADDRESS(If different from Owner's Address) Attention orCare of MAILING ADDRESS CITY STATE ZIP G�33E� TYPE OF OWNERSHIP: CORPORATION❑ INDIVIDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ FACILITY FILE FACILITY ID#: CO-OWNER ID#: ACCOUNT ID#: COMPLETETHEFOLLOW/NG BUSINESS FACILITY/NFORMAuolv.' Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPAR T ME NT? YES NO ❑ Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No I(� BUSINESS/FACILITY NAME(This will be the BUSIN NAtrEon the HEALTH PERMIT) ��1� Gouc-NlC �7er'(j?,;:1 FACILITY ADDRESS(If FAclLnvis a MosILEFOOD UN/ror FOOD VEHicLEL a the COMMISSARY ADDRESS BUSINESS PHONE Suite# CITY(If FAGLmis a MOBILE FOOD UNrror FOOD VEHIcLE use the COMMISSARY CRY) STATE zip r f�G IX BOARD OF SUPERVISOR DISTRICT LOCATION CODE 7 KEY1 KEY2 MAILING ADDRESS for Healo PefMfl(lf DIFFERENTfrom FacffftyAddress) Attention orCare Of MAILING ADDRESS CITY ? STATE C,/I ZIP ��3 SIC CODE: APN#: COMMENT: ACCOUNTADDRESS for fees and charges: OWNER FACILITY/BUSINESS ❑ BILLING AND COMPLIANCE ACKNOWLEDGMENT: ],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: / !G/l a / �. S LICENSE# at/V♦ DATE /� /� PHOTOCOPY REQUIRED) Approved By VrL I t� Date �C� Accounting Office Processing Completed By Date 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 except UST Program(Use SWRCB forms) EHD 48-02-035 Masterfile Record-Green 11/27/07