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,r SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE1^RECORD INFORMATION FORM SHADED SEcxw;FOR EHD USE ONLY OWNER ION �YV LY�'L�lp(� CASEN OWNER FILE COMPLErETHEFOLLOW/NGBUSINESS OWNER INFORMATION: CHEcx it OWNER CURRENTLYONFILE wnNEND❑ BUSINESS PHONE: OWNER'S NAME n R,, I,1, BUSINESS NAME(IT dh%e f fi owner Name) SOC Sao orTax ID N "1 OWNER'S HOME ADDRESS: I ` CITY STATE l• . ZIP OWNER'S MAILING ADDRESS(110lierenf FrornOwners Address) Attention orCare of MAILING ADDRESS CITY STATE ZIP TYPE of OWNERSHIP: CORPORATION❑ INDIVIDUAL PARTNERSHIP❑ LOCALAGENCY❑ COUNTYAGENCY❑ STATE AGENCY❑ FED AGENCY OTHER[I FACILITY FILE FACILIT'ID#: CO-OWNER ID#: ACCOUNTID#: �W COMPLETE THEFOLLOW/NGBUSINESS FACILITY INFORMATION: Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? I YES ❑ ND ❑ Is this an EXISTING Business LOCATION but a NEW TYFE of regulated Business? YES ❑ NO ❑ BUSINESS/FACILtrY NAME(This will tre Ne BmNEss NAaeon Ne HEALTH PERMIT) APN: FACILITY ADDRESS(if FAC/ 18 a MOeaefcub Umror Fano Vewrc use the COMMISSARY AGONEs91- auSINUS PHONE Sbeetm ber 1 precf/on Sheet Nemo I Street 11,,, 1 Su,re4 CRY Of FAourYisa Mo611E Fool,UMror FooO VewctE me the Cownessuiw Crt'A STATE ZIP BOARD OF SUPERVISOR DISTRICT LOCATION Code KEY1 KEY2 MAILING,ADDRESS forHBB/th PeirMit(If O/FFEREA?fYom Fac//ifyAdoress) Attention crCare Of MAILING ADDRESS CITY MCCA STATE r`.IL ZIP EMAIL ADDRESS FOR INVOICE �T 0O Usy�-I�'j INVOICE l;YT "1 INVOICES EMAIL l EMAIL2 EMAIL ADDRESS FOR PERMITu \� PERMIT J� OPERATING PERM ITS EMAIL'I EMAIL2 -1\� 1' Agee UORE33 for fees end ChergB3: OWNER ❑ FACILITY/BUSINESS ❑ BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,Certify that I am the Owner,Operator,or AuNoriZed Agent Of this Business,and I acknowledge that all PERMR FEES,PENALTIES ENFORCEMENFCHARGES and/or HOURLY CHARGES associated With this operation will be billed W me at the address identified above as the AceduNrADOREss 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 andlor Standards and STATE andlor FEDERAL taws and Regulations. APPLICANT'S NAME: SIGNATURE: P/ eP of DATE 1 DRNFJI'SUC%`dUI ;L pip TRS' �Ia'V 2PHOTOCOPY RE UIRED OA �r APyowW By DW A000un ing Was ProonIs re ComPlebd 6y Cab A PROGRAM(END 48-02-034 Pink)OY WATER SYSTEM(EHD 48-02-003)form LnL*be Completed for each EHD regulated operation at this LOCATION except UST Program(Uae SWRCS forms) . EHD 4502-035 Masterfile Record-Green 8/142020