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Wff 0 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM SwEDSEcwNSFDREHDUSEOmy OWNER ID# /}��5 'p CASE# OWNER FILE 'tk r" COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATIOIY; CHECK IF O NERCuRRENTLrpnrFllEwttHEHD 'gyp BUSINESS ei � FPHOWNER NAME M1 LEast ygy i BUSINESS NAME(If dtTerent ft Owner ame) Soc Sec orTax ID# E a c s 5";-?- 13 - OWNER HOME ADDRESS V � CITY O C_ S ZIP 'Ka OWNER MAILING ADDRESS(If different Owner Address) Attention or Care of i MAW NG ADDRESS CITY $ ZIP(7 � 5-2-o TYPE OF OWNERSHIP: SC CORPORATION❑ INDMDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ FACILITY FILE FACILITY ID#: fj6,p10 1 17 CO-OWNER ID#: ACCOUNT ID#: 3 3 COMPLETE THE FOLLOWING 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 BuSINER 1 LITY�N e ¢. E the HEALTH PERMIT) FACILITY ADDRESS If FAcrury is a osrt_EFooa un or FOOD VEH=c use the Commrsg6M AnDRE4I BUSINESS PHONE �7 pji.ar V0. L Suite# 6,10- 5691 �1 CITY(IfFAa�MofvLE FOOD Unnr or Foos Va4icLE use the CommiRsARY ri Swg ZIP ` - 0i 15� BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEYS KEY2 MAILING ADDRESS for health Pen171t(If DIFFERENTfrom Facility Address) Attention orCare Of S P�rAp-- MAI N DDRrCITY SIC CODE: APN#: COMMENT: Accouw for fees and charges: OWNER FACILITY/BUSINESS ❑ C : I, the undersigned Applicant, certify that I am the Owner, Operator, or Authorizer!Agent of this Business,and I acknowledge that all PERMIT FEES,PENALTtE's,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation will be billed to me at the address identified above as the A2GOUNTADDREc4 for this site. 1 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 SA AQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or FEnERAL Laws and ReLyulations. k APPLICANT NAME�-J v M L n L (I &"t SIGNATURE: P se Print f k y! TITLE: DATE DRIVER'S LIC NSE# Approved By Date Accounting Oftice Processing Completed By k C7 /Date L C� A PROGRAM{EHD 4M4034 Pink}or WATE SYSTEM tEHD 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 1019!2003