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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM SHADED SECTIONS FOR EHD USE ONLY OWNER ID III b) oz) I 7SI CASE# v OWNER FILE COMPLETE THEFOLLOw/NG BUSINESS OWNER/NFORMAT/ON' CHECK IF OWNER CuRRENTz r cNF&E wirHEHD❑ BUSINESS /J •G��e � (� r1rV_L" PHONE: OWNER'S NAME IC�j� _ /(�Gh ^ First MI Last BUSINESS NAME(if diReneritkolpo nerName) Sao See OrTaz ID III / fo -eFC "OO..,,/ 78/ 7 OWNER'S HOME ADDRESS ,y�2Gi' �� p vY w��v2 L/ .il/+o V-f CITY // O Y/ .?A E ZIP vt tl'7� s^ L` OWNER'S MAILING ADDRESS(if diHerenllroinOwnere Address) Attention orCaro of[ MAILING ADDRESS CITY STATEs`rr C ZIP fp S / ;5;: D Type OF OWNERSHIP: CORPORATION El INOIVIDUAL�6 PARTNERSHIP E] LOCAL AGENCY❑ COUNTY AGENCY El STATEAGENCY❑ FED AGENCY El OTHER El FACILITY FILE pp FACILITY ID#: d Q CO-OWNER ID#: ACCOUNT ID#: t V COMPLETE THEFOLLOw/NG BUSINESS FACILITY/NFORMAT/ON.' ��// IS this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO 2< Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YESU NO ❑ BUSINESS/FACILiTY NAME(This will be the BUSINESSAAmeon the HEALTH PERMIT) FACILITY ADDRESS(MFActurris a MOasrFoco UNlror FOOD✓r:Hxc usa the COMMISSARY ADDREssI BUSINESS PHONE / ! ZF/ ,,2 i (.leraol wuc C� � Suite# ; r�6-776 1G 0 CITY(IfFAuuNis a Moe2EFOOD UNrror FOOD VEHICLE use the CoMMIssARY Cm) STATE ZIP WV ,v Ctl �;s6�/ BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEYi KEY2 MAILING ADDRESS for Health Pelflflt(If DIFFERENTfrom Facility Address) Atfenuon orCam Of MAILING ADDRESS CITY STATE ZIP SIC CODE: APN#: COMMENT: ACCOUNTADDff$$fclrfees 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 to me at the address identified above as the ACCOUNT ADDRESS 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: t GN /CG (/� // /FCJI`s SIGNATURE: off` Please Print TITLE: r,l Th DATE 6 /- if DRIVER'S LICENSE '\ O I-T 7(Z PHOTOCOPY REQUIRED Iv I c--CJ Approved Dete Z� Aeeounting Office Processing Completed By Data & 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!27107