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SAN JAIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> SHADED SECTIONS FOR EHD USE ONLY OWNER I D# CASE# <br /> OWNER FILE <br /> COMPLETE THE FOLLOW/NG BUSINESS OWNER INFORMATION: A 1 CHECKIF OWNER CURRENTL YON FILE WITHEHD[:] <br /> BUSINESS V'ev i N cCKMA W PHONE L� <br /> OWNERNAME First MI I Last <br /> BUSINESS NAME(If different from Owner Name) ,q , t. { -r� 1 N E Soc Sec orTax ID# <br /> OWNER HOME ADDRESS ly ►-lJ <br /> CITY — � "— STATE ZIP <br /> OWNER MAILING ADDRESS(If different from Owner Address) Attention orCare of <br /> 0-1C WE&T IAWE ICI=ViN ECK�MAN <br /> MAILING ADDRESS CITY (/7TG C-k 1-0 $ ZIP qSZ 1(i <br /> TYPE OF OWNERSHIP: <br /> CORPORATION❑ INDIVIDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID#: CO-OWNER ID#: I ACCOUNT ID#: <br /> COMPLETETHEFOLLOW/NG BUSINESS FACILITY INFORMATION: / <br /> Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES El No 2 <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES 1:1 No LJ <br /> BUSINESS/FACILITY NAME(This will be the BUSINESSNAMEOn the HEALTH PERMIT) SCO N C LUBE,y�C7 E A TU N E <br /> FACILITY ADDRESS(If FAC/L/TYIS a MOBILEFOOD UNror FOOD VEHICLEUSe the COMMicsnRv nooaec_s� `t BUSINESS PHONE <br /> �q�0 (11 WEOT 1-11.i>= (201)4.13-4-503 <br /> Suite# <br /> CITY(if FACILITY isaMOBILE FOOD UNIT orFOOD VEHICLE use the CnMMIRS av .ITV) `TCCK-MW STATE ZIP <br /> 1. C,�{ . 952- IC, <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEPI KEY2 <br /> MAILING ADDRESS for Heath Permit(If DIFFERENTfrom FacifityAddress) Attention orCare Of <br /> _7 <br /> MAILING ADDRESS CITY STATE ZIP <br /> SIC CODE: APN#: COMMENT: <br /> ACCOUN"DDRESS-for fees and charges: OWNER ❑ FACILITY/BUSINESS ❑ <br /> IIn,vim: AND CoMPI IANCR ACKNowizaciMRNT: 1, the undersigned Applicant, certify that I am the Owner, Operator, or Authorized Agent of this <br /> Business,and I acknowledge that all PERMIT FEES,PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation will be <br /> 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 <br /> and correct; and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL`.Laws and Re ulations. <br /> APPLICANT NAME: I A V L A 1 I" f C r\ SIGNATURE: , <br /> TITLE: r K 6 J F—LT M AeF.5e0C6'E F DATE C L 4 DRIVER'S LICENSE# <br /> Approved By Date Accounting Office Processing Completed By Date <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 I OrATION <br /> except UST Program(Use SWRCB forms) <br /> EHD 48-02-035 Masterfile Record-Green <br /> 10/9/2003 <br />