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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> SMQE0SECTI0t4F0REHDUse0&Y OWNERID# I IL CASE# <br /> OWNER FILE <br /> COMPLETETHERXLOWIAG BUSINESS OWNER/NFORM4TION.- CHECKIFOWNER CWMFNny0NnLEWTHEHD❑ <br /> BUSINESS ; �{ 1 � � PHONE: <br /> OWNER'S NAME F63t M1 Cast 6 — <br /> BUSINESS NAME(if ddrorcntrmmOwner <br /> Nome) 8o Sec orTax ID# <br /> Zvi e Fl&v%ts 1-^4 00115 OS <br /> OWNER'S HOMEADDRESS: <br /> CITY LZVN`e>, STATE C14- ZIP q s a 36 <br /> OWN ER'S MAILING ADDRESS(If drerent ft=Own er'e Addr=o) A ttention orCere of <br /> MAILING ADDRESS CITY STATE LP <br /> TYPE OFOWNERMIP. <br /> CORPORATION INDMDtAL❑ PARTNERSHIP❑ LOCALAGENOYIJ COUNTYAGENCY❑ STATEAGENLY❑ FEDAMCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID#: CQ-OWNER ID#: ACCOUNT ID#: <br /> COMB ZrETHEFOLLOWING BUSINESS FACILITY t'NFORNA7)ON.' <br /> Is this a NEW Business LOCATION or VEHICLE not oviously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO <br /> Is this an E)WTNG Business LOCATION beta NeNTYPE of regulated Business? YES NO ❑ <br /> B U SINESSIFAumy NAME(This will be the BusmessNAWon the HEALTH PERMIT) APN: <br /> onvl,e <br /> FA ciuTY ADDRESS of FAcxny 13 a Maoxf FOOo t.AYror F000 VEvcLFuse the COMMISSARY ADDRESS) BUSINESS PHONE: <br /> a 3� E . "I l,'Ae-, CA 01 sa3 b <br /> CITY(It FAuurris a Moans Fcoo UNnor FOODVEroctE use the COMMISSARY Cm) STATE ZJP <br /> CA- 9 sd.3 <br /> BOARDOFSUPERVIsoRDmmcT LOCATIONCODE KEYI KEY2 <br /> MAILING ADDRESS thrHealffi POMIt(If DIFFERENTfrom FaaldyAddress) Attention orCare Of <br /> MA ILING ADDRESS CITY STATE Z I P <br /> EMAILADDRESSFOR INVOICE I I 1 L INVOICE <br /> INVOICES EMAILI LJ� 0 f yh►Il ) EMAIL2 <br /> EMAILADDRESSFOR PERMIT ; C'. _ ,r� �� PERMIT <br /> OPERATING PERMITS EMAILI YVt WtrAU 0 � Yiyf) EMAIL2 <br /> ACCOUNTADDRESSfor fees and chargas: OWNER ❑ FACILITY/BUSINESS <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certiythatlamtheOwner,Operator,orAuthoraedAgentof this Business, <br /> and I acknowledge that all PERmT FEES,PENALTIES,ENFORCSENTCHARGES and/or HOURS YCttARGEsassociated with this operation will be billed to me at <br /> the address Identified abovea3 the AccouivrADDREss for this site.I also certify thatall Inforrnation provided on this application Is true and correct; and <br /> that all regulated activities will be performed In accordance with all applicable SAN JoAquN CouNTY Ordinance Codesand/or Standards and STATE and/or <br /> FEDERAL Laws and Regulations. II 1 <br /> APPUCANT'SNAME: ( c Lh I�/nAr Ila SIGNATURE: / <br /> 00- <br /> TITLE: pS� \ ;a Print DATE li I a,o�,� DRHOTOC:OPYRE URED I�� a�q0 J' <br /> Approved 9y Date Ae co,ntkV Offee Ptocouft Competed By Data <br /> A PR oGRAm JEHD 48-02-034 Pin k)orWATER SYSTEM(EHD46-02-003)form must be completed for each EHDregulated op,eratIon at this LOCATION <br /> except UST Program(Use SWRCB fiorms) <br /> EHO48-02-035 Masterfile Record-Green <br /> 911412020 <br />