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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM SHADED SECRONS FOR EHD USE ONL Y OWNER ID# b W pot7S-L, CASE# OWNER FILE COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION: CHECK/F OWNER CuRRENTC YON FILE WITH EHD❑ BUSINESS /J C `7W,e"U/ (-[j awul "5' �PyHONE: OWNER'S NAME Vl Fint MI Last 7/l, ` � /6c:xj ^ BUsINess NAME(If�d#1%,nxnthoLaOwnarNsms) See Sec oF(T�e%ID Y p. 7O / 7 OWNER'S HOME ADDRESS ,L/r2Gr' Wt• d,.ao�/¢�Y �'f4(vt�•� ./,J/'Ev-r t." r^ D v " ZIP OWNER'SI,MAUNO ADDRRESSS(IfdMnentfr Owners Addrsss) Attention orGare of C_l�trr-.tG� MAILING ADDRESS CITY (? STATE ZIP TYPEOFOWNERSHIP: CORPORATION (NDIVIDUAL)�k PARTNERSHIP El LOCAL AGENCY COUNTY AGENCY El STATE AGENCY El FED AGENCY E) OTHER❑ FACILITY FILE FACILITYIDM D Q CO.OWNERID#: ACCOUNT 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:pi NO ❑ BU' SINEs3/FACILITY NAME(This will be the BuswN sNAMEon the HEALTH PERMIT) fit _).t'A Jam: 5 < 1-C /vv b i n FACILITY ADDRESS(If FACAUTYIea MomLEFOoo UNlrer Fooc✓EHICLEMw the COMMISSARY ADDRESS) BUSINESS PHONE /VA to/ R I,4-�(,e e�o ' as r 2 Suite tt l/6 776 /G d" CITY(If FACIInYK a Moe,EF000 UMror Foos VEMcLEuse the COMMISSARY CmI STATE ZIP tt/vl V C 0 ; G 74 BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY7 KEY2 MAILING ADDRESS for Health Petr»d(If D/FFERENTfrom Fac//ityAddress) Attention orCare Of MAILING ADDRESS CITY STATE ZIP SIC CODE: APN OF. COMMEW: ACCOUNTADDRESSfor fees and charges: OWNER FAcnUTY/BUSINESS ❑ BILLING AND COMPLIANCE ACKNOWLEDGMENT: [,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 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. nn APPLICANT'S NAME: i C//44KA (/-/ /�2/7zrJ 1 SIGNATURE: v Please Print ' TITLE: LICENSE# ,4ev Mt< DATE -oJ�- �1 DRIVER'S TOCOPY REQUIRED Iv ZCJ C� ApprovedDab Accounting Office Processing Completed By Dao. 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