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SAN JO,�QUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT IVIASTERFILE RECORD INFORMATION FORM SHADED SECTIONS FOR EHD USE ONLY OWNER I D# I'I/HOZ z G)11 CASE# OWNER FILE COMPLETETf-/EFOLLOw/NGBUSINESS OWNER/NFORMAT/ON: CHECKIF OWNER CURRENTLYON�FILEWITHEHD❑ BUSINESS i+�dl� 4vi i2 Co •r.�i PHONE: —0 1 OWNER'S NAME f„ 2 2 First l�41 La U( _ 7 BUSINE S ME(If different from Owner Namr) Soc Tax ID# Na aro V A�CS IT�YLt,i f s - OWNER'S HOME ADDRESS J--1\L1 O'6 vc C} CITY w a,1 S" ZIP(t S ZL OWNER'S MAILING ADDRESS (If different from Owner's Address) Attention or Care of`j� ` I 0 11 V`e G4- • Pd O A✓1 'Q • cO 1.2.1 MAILING ADDRESS CITY �O��` Syz�e ZIP TYPE OF OWNERSHIP: CORPORATION❑ INDIVIDUALV PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY OTHER❑ FACILITY FILE FACILITY ID#: ICO-OWNER ID#: ACCOUNT ID#: COMPLETE THEFOLLOw/NG BU SI NESS FACILITY INFORMATION; Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES NO ❑ Is this all EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES NO ❑ BUSINESS/FACILITY NAME(This will be the BuswEss NAMEon the HEALT PERMIT) t 1I ncA VA kg 7r_,�' FACILITY ADDRESS(IfFAcruTris a MOSILEFOOD UNITDr FOOD VEHICLEuse the COMMISSARY ADDRESS) yBu&sINESS PHONE Z� f1 v`� iteCITY(IfFACIL TYIs a Moe LEFDDO UNITOr F000 VEHICLE U50 the COMMISSARY CITY) STF}T.� BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEYI KEY2 MAILING ADDRESS for Health Permit(If DIFFERENTfrom Facility A ddress) Attenti n or Care Of LAw 10 �t Am n D CC7 1�1 MAILING ADDRESS CITY STAM ZIP' t Z`� r ,rl 3 SIC CODE: vAPN#: COMMENT: I ACCOUNTADDRESS for fees and charges: O NER FACILITY/BUSINESS ❑ 31LLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner, Operator,or Authorized Agent of this Business,and acknowledge that all PERMIT FEES,PENALTIES, ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this Operation will be billed to me at the ddress identified above as the ACCOUNTADDRESS for this site. I also certify that all information provided on this application is true and correct;and that II regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or EDERAL Laws and Regulations. APPLICANT'S NAME: AG��" n In �Q I/LC� SIGNATURE: Please Print TITLE: DATE DRIVER'S LICENSE# ^ PHOTOCOPY REQUIRED Approved By Date I 1 _ _,,I` Accounting Office Processing Completed By Date 7/ 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 <cept UST Program(Use SWRCB forms) ID 48-02-035 Masterfile Record-Green 19/08