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SHADED SECTIONS FOR EHD USE ONLY SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM OWNER ID # �W�Z� CASE # OWNER FILE COMPLETE THEFOLLOW/NG BUSI NESS OWNER /NFORMAT/ON: CHECK IF OWNER CURRENTLYON FILE WITHEHD❑ CORPORATION ❑ INDIVIDUAL � PARTNERSHIP ❑ LOCAL AGENCY ❑ COUNTY AGENCY FACILITY FILE STATE AGENCY ❑ FED AGENCY ❑ OTHER ❑ FACILITY ID Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES #: �� CO OWNER ID #: dh%UV ACCOUNT ID #: , ,' BUSINESS OWNER'S NAME kz `'1N /ems /NFORMAT/ON: APN: PHONE: �51C - 0 First MI Last BUSINESS NAME (If differ nt from(Owner Name) SOe Sec or Tax ID # F R-�-� O� J �S Wq 1 U"� 1RU OWNER'S HOME ADDRESS: k ZA W 9 ve CITY Q { �% I Direction STATE G, ZIP OWNER'S MAILING ADDRESS (If different from Owner's Address) Attention or Care of MAILING ADDRESS CITY STATE ZIP n r/ I ZIP � -2,o4 !' (J� BOARD OF SUPERVISOR DISTRICT CORPORATION ❑ INDIVIDUAL � PARTNERSHIP ❑ LOCAL AGENCY ❑ COUNTY AGENCY FACILITY FILE STATE AGENCY ❑ FED AGENCY ❑ OTHER ❑ FACILITY ID Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES #: �� CO OWNER ID #: dh%UV ACCOUNT ID #: , ,' COMPLETE THE FOLLOW/NGBUSINESS FACILITY /NFORMAT/ON: APN: 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 NO ❑ Is this an ExISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No Office Proceeeing Completed By Dete �� '� �7 BUSINESS/FACILIl,`f�[�iA E (T is will ab,Sthe BuswEssNAMEon the HEALTH PERMIT) JFOOD APN: FACILITY ADDRESS (If FACIurYis a A40BiLEEF000JDGUNN'iTor VEHiCLEEUServiyhe COMMISSARY ADDRESS) I jt�+ N "RSV • S etu KN N GNB �l q2 ty BUSINESS PHONE: -T ,O • 2�- Street Number I Direction Street Name Street Type Suite # CITY (If FAcatTYls a MOBILE FOOD UNITor FOOD VEHICLE the A� oMMISSnRY CITY) t, ` vLvOCCA``T-IIOO11•N\'ICODE STATE n r/ I ZIP � -2,o4 !' (J� BOARD OF SUPERVISOR DISTRICT FKEY1 FKEY2 MAILING ADDRESS fOr Health PerM t(lf DIFFERENTfrom Facility Address) Attentlon orCareOf " 7 NA;Wrr pQjGC4 ?4Vb MAILING ADDRESS CITY A2`I p1t,t�iWWO Oe, � �{�kizo `II `, �� STATE Gk ZIP at PJ330 EMAILADDRESS FOR INVOICES [INVOICE MAIL 1 �� n�^`e'il l/ mQ( I' CCW INVOICE EMAIL 2 EMAIL ADDRESS FOR OPERATING PERMITS PERMIT EMAIL1 PERMIT EMAIL2 ACCOUNTADDRESS for fees and charges: OWNER FACILITY/BUSINESS ❑ Operation Will be billed t0 me at the address identified above as the AccounlrADOREss 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 Requlations. r��1 APPLICANT'S NAME: � Please Print SIGNATURE: DATE ID 'S LICENSE # A PROGRAM {EHD 48-02-034 Pink} or WATER SYSTEM (EHD 46-02-003) form must be completed for each EHD regulated operati Approved By �,��, , to � I 30' 1:1,Accounting Office Proceeeing Completed By Dete �� '� �7 on at this LOCATION except UST Program (Use SWRCB forms) EHD 48-02-035 Masterfile Record -Green 9/14/2020