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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM SHADED SECTIUNSFUREHD USEONLY OWNER ID# CASE# OWNER FILE COMPLETE THE FOLLOW/NG BUSINESS OWNER INFORMATION.' CHECK IF OW N ER CuRREivrc r oN FicE wirH EH D❑ BUSINESS PHONE: OWNER'S NAME p L// First MI Last BUSINESS NAME(If ,differ tfrom Owner Name) Soe Sec orTax ID# OWNER'S HOME ADDRESS SGo �. • CITY r�yrs SM zip s. OWNER'S MAILING ADDRESS (If different from Owner's Address) Attention orCare of MAILING ADDRESS CITYTATE ZIP SZ TYPE OF OWNERSHIP: CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ FACILITY FILE FACIGTY ID.#: CO-OW/ ER ID'#: ACCOUNTID#: COMPLETE THEFOLLOWING BUSINESS FACILITY INFORMATION.' 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 M (This will be the BusnvESsNAmEon the HEALTH PERMIT) 116f4�4 7"J FACILITY ADDRESS(ff FACILtrris a MOL71LEF000 UN/ror F000 VEHICI Euse the COMMISSARY ADDRESS) BUSINESS PHONE 5�'G P ' v-1 G/, 7n'A(�Streetftm&er Suite CITY(If FACtLiTYIs a MOBILE FOOD UNIT or FOOD VEHICLE use the COMMISSARY CITY) STATE zip BOARD OF SUPE4V,15OR DISTRICT LOCATION CODE KEY1 KEY2 MAILING ADDRESS for Health Perm t�DIFFERENTfrom FacihtyAddress) Attention orCare Of G MAILING ADDRESS CITY {� STAT O(In zip ys z3 SIC CODE: APN#: COMMENT: ACCOUNTADORESS for fees and charges: OWNER ❑ FACILITY/BUSINESS BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,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 Re ulations. APPLICANT'S NAME: 7L4 SIGNATURE: e P/ease Print TITLE: DATE DRIVER'S LICENSE# :21 `T O PHOTOCOPY REQUIRED 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 each EHD regulated operation at this LOCATION except UST Program(Use SWRCB forms) EHD 48-02-035 Masterfile Record-Green 11/27/07