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SAN JO.._JIN COUNTY ENVIRONMENTAL HEALTH L ARTMENT MASTERFILE RECORD INFORMATION FORM SHADED SECTIONS FDR EHD USEONLY OWNER ID# D��D I o IST CASE# OWNER FILE COMPLETE THE FOLLOW/NG B U S I N ESS OW N ER INFORMATION: CHECK/F OWNER CURRENTL r oN F1LE wITH EH D❑ BUSINESS Z P ONE: OWNER'S NAME - First M/ Last BUSINESS NAME(If different from OwnerN me) SeC rTax ID# � ce 60 2_1- 0152 OWNER'S HOME ADDRESS O �� S �l. ��, �7, 1-71,6 CITY STATE ZIP OWNER'S MAILING ADDRESS (If different from Owner's Address) Attention orCare of s MAILING ADDRESS CITY STATE ZIP TYPE OF OWNERSHIP: CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ FACILITY FILE FACILITY ID#: UO Z�_ S CO-OWNER ID#: ACCOUNT ID#: �Q[� "2 g COMPLETETHEFOLLOW/NG BUSINESS FACILITY/NFORMAT/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 HusmEssNA Eon the HEALTH PERMIT) Li FACILITY AD RESS(If FACILITYIS a MOUILEFOOO UN/Tor FOOD VEHICLEUS8 the COMMISSARY ADDRESS) BUSIN SS PHONE Suite# CITY(If FAcILITYIs a MOBILEFOOD UN/Tor FOOD VEH/CLEuse the COMMISSARY CITY) STATE ZIP BOARD OF SUPERVISOR DISTRICT �, LOCATION CODE KEY1 KEY2 MAILING ADDRESS fOr Health Permtt(If DIFFERENTfrom Facility Address) Attention orCare Of MAILING ADDRESS CITY STATE ZIP SIC CODE: APN#: L _ U C _ G�7 COMMENT: ACCOUNTADDRESS 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 t0 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: 5 v4ly`� l L ! G �� ! SIGNATURE:.- 7E;a L(A S �.V U 2 9 TITLE: Please Print DATE it/ 5 I/ 7 DRIVER'S LICENSE# CL PHOTOCOPY REQUIRED Approved By /i f V�7 Date i 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