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J SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM SHADED SECTIoNSFOR EHD USEONLY OWNERID# CASE# OWNER FILE COMPLETE THEFOLLOW/NGBUSINESS OWNER INFORMAT/ON.' CHECKIF OWNER CURRENTLYONF/LEw/THEHD❑ BUSINESSAky PHONE' OWNER'S NAME First MI Last BU�SI�j'ESS NAME(If different from Owner Name) Soc Sec orTax ID# OWNER'S HOMEADDRESS CITY ��l l 1�lJ ZIP �o OWNER'S MAILING ADDRESS(If wner's Address) Attention orCare of MAILING ADDRESS CITY 1 3 FT�ATE ZIP 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 INFORMAT/ON.' Is this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO ❑ Is this an EXISTING Business LOCATION but a NEw TYPE Of regulated Business? YES ❑ No ❑ BUSINESS/FACILITY NAME(This will be the BUSINESSNAMEOn the HEALTH PERMIT); Ufa/l,. /q: FACILITY ADDRESS(If FACILnYIS a MOB/LEFOOD UNlror FOOD VEHICLEuse the COMMISSARY ADDREss) CU/ (BUSINESS PHONE Street Tyr& Sine CITY(If FAG(!�I$afNO�IF FOOD UNITOrFOOD VEHICLFuse tIlECOMMISSARY CfTY) .STATE ZIP vp BOARD OF SUPERVISORDIISTRICT LOCATION CODE KEY1 C/J/`/ KEY2 J J MAILING ADDRESS for Health Perm/t(lf DI\FFEEREN(Tfrom F/a�cilityAddrressss) Attention orrCare Of p _ � _ C��y.� .tc. MAILING ADDRESS CITY v STAT ZIP(� SIC CODE: APNM COMMENT: ACCOUNTADORESS for fees and charges: OWNER ❑ FACILITY/BUSINESS ❑ BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,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. / f APPLICANT'S NAME: //p�� jam I�1 Z- SIGNATURE: /A/i�/•I/,/�!�{ )4.�U ` YREQUIRED \. )�/u-) Approved By t Date 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