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&t`` I SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT n❑�� MASTERFILE RECORD INFORMATION FORM SEP 17 2004 SHADED SECnONSFOREHD USE ONLY OWNER ID# �(J Otllpa-� CASE# ENVIRONMENT HEALTH OWNER FILE COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION: CHECKIF OWNER CURRENTLY ON FILE MTHEHD BUSINESS PHONE OWNER NAME First MI Last BUSINESS NAME(If dAte2nt from Owner Name) Soc SEC or Tax ID# 94-2490255 Berberian Properties, LLC 7 OWNER HOME ADDRESS CITY STATE ZIP OWNER MAILING ADDRESS(If different from Owner Address) Attention or Care of 515 Lyell Drive, Suite 101 Robert Vans ronsen MAILING ADDRESS CITY Modesto S6YE ZIP 95356 TYPE OF OWNERSHIP: S6 CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER FACILITY FILE FACILITY ID#: CO-OWNER ID#: ACCOUNT ID#: IK-] oX COMPLETE THE FOLLOWING BUSINESS FACILITY INFORMATION: pp�� 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 ❑ wr BUSINESS/FACILITY NAME(This will be the BusiNEss NAME on the HEALTH PERMIT) f3Fe— _ L) I & L�f6k!!P FACILITY ADDRESS(H FACILITY is a MOBILE FOOD UNIT Or FOOD VEIUCLE use the C�OMMIC¢ARY ADDRFsBUSINESS � s) BUS IN ESS PHONE 26237/26239 E. Mriller Ave Street N r Suite# 209-578-5800 CITY(If FAaUTYisaMOBILE FOOD tRJrTorFOOD VEHICLE Use the COMMISSARYCm) STATE ZIP 5320 BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 MAILING ADDRESS for Health Permit(if DIFFERENT from Facility Address) Attention or Care Of MAILING ADDRESS CITY STATE ZIP H,�j '-z?fl Lt C0 0 0 q _C&'A ACCOUNT AnnRESS for fees and charges: OWNER 0 FACILITY/BUSINESS ❑ BIIJ.ING AND COMPI.IANCF ACKNOwLFDGMFNT: 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 AccOUNTADDREcc 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 JO.AQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or FEDERAL Laws and Re ulations. LAPPLICANT NAME: SIGNATURE: "t/ Please Print TITLE: DATE DRIVER'S LICENSE# D0063860 Approved By 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 earb EHD regulated operation at this LOCATION except UST Program(Use SWRCB forms) EHD 48-02-035 Masterfile Record Wen 10/9/2003 1 OF043 A I A