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* SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> SHADED SECTIONS FOR EHD USE ONLY IL OWNER I D# Q w cy' 2q,OLOLLCASE# <br /> OWNER FILE <br /> COMPLETE THE FOLLOWING <br /> //BJJUSINESS OWII NNZER/NFORMAT/ON: CHECK IF OWNER CURRENTLYON FILE W/THEHD❑ <br /> OWNERBUSINESS NAME �Ll vL 11`> I=JL� -�I -1C,1� WII ( kY �/ P ONE: <br /> FiMI ----Ta—s, i `�l <br /> BUSINESS NAME(If different from Owner Name) Soo Seo orTaX ID# <br /> T i etc �l vY�)CA <br /> OWNER'S HOME ADDRESS: <br /> CITY STATE ZIP <br /> OWNER'S AILING ADDRESS (If different from Owner's Address) Attention orCare of <br /> MAILING ADDRESS CITY STATE ZIP -�C� 7 T2 <br /> TYPE OF OWNERSHIP: C l/ <br /> �- <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID#: ?j � I CO-OWNER ID#: ACCOUNT ID$F: v <br /> COMPLETE THE FOLLOWING BUSINESS FACILITY/NFORMAT/ON: <br /> Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES NO ❑ <br /> Is this an ExISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No [] <br /> BUSINESS/FACILITY NAMEThis ill be the BUS/NESS NgMEon the HEALTH PERMIT) APN: <br /> -1 t . 1tC� , C) �s 1S0 C) <br /> FACILITY ADDRESS(If FAC/L/TYIS a MOB/LEFDOD UNlror FOOD VEHICLEUSO the COMMISSARY ADDRESS) BUSINESS PHONE: <br /> Street Number Direction Street Name Street Type Suite# <br /> CITY(If FACILITY IS a MostLE Foop UNITor FOOD VEHICLE use,the COMMISSARY Cl ) STATE ZIP <br /> C71, <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEYI KEY2 <br /> MAILING ADDRESs�fO .He PB/%/i't(I D= F@ci/ityAddress) Attention orCare Of <br /> \ <br /> MAILING ADDRESS CITY o, 2 STATE 1 ZIP <br /> EMAIL ADDRESS FOR INVOICE 1�`Y/l C_4)V)_) INVOICE l <br /> INVOICES EMAIL 1 EMAIL 2 <br /> EMAIL ADDRESS FOR PERMIT PERMIT <br /> OPERATING PERMITS EMAIL1 EMAIL2 <br /> ACCOUNT ADDRESS for fees and charges: OWNER FACILITY/BUSINESS ❑ <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and <br /> I acknowledge that all PERMIT FEES, PENALTIES, ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this Operation will be billed to me at the <br /> 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 <br /> all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or <br /> FEDERAL Laws and Regulations. <br /> APPLICANT'S NAME: SIGNATURE: <br /> Please Print <br /> TITLE: DATE DRIVER'S LICENSE# <br /> PHOTOCOPY REQUIRED <br /> Approved By Data Accounting Office Processing Completed By Date <br /> d <br /> 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 <br /> except UST Program(Use SWRCB forms) <br /> EHD 48-02-035 Masterfile Record-Green <br /> 9114/2020 <br />