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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM SHADED SECTIONS FOR EHD USE ONLY OWNER ID# CASE# OWNER FILE COMPLETE THE FOLLOW/NG BUSINESS OWNER /NFORMAT/ON. CHECKIF OWNER CURRENTLY ON FILE WITH EHD BUSINESS PHONE OWNER NAME First M/ Last BUSINESS NAME(If different from Owner Namj) Soc Sec or Tax ID# OWNER HOME ADDRESS CITY ZIP O OWNER MAILING ADDRESS (If different from Owner Address) Attention or Care of PO -1 MAILING ADDRESS CITY \, ; O✓^ T ZIP TYPE OF OWNERSHIP: v CORPORATION Rr INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY OTHER❑ FACILITY FILE FACILITY ID#: �}�vb 33SS CO-OWNER ID#: ACCOUNT ID#: N-ebb`A 31]`77 COMPLETETHEFOLLOW/NG BUSINESS FACILITY INFORMATION; Is this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES, NO ❑ Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No BUSINESS/FACILITY NAME(This will be the Bus/NEss NAnrEon the HEALTH P�.RMIT) Ll ✓01 k ti o�-� �. �2r✓ L . FACILITY ADDRESS(If FAC/Uryis a MOBILEFOOD UN/Tor 100D VEHICLEUSe the COMMI tsARY AnnRFss) BUSINESS PHONE l 7�14 b _ Suite# CITY(If FACILITY Is a MOBILE FOOD UNIT or FOOD VEHICLE use the CnMMissARY CITY) STATE Zip 9`-�z�0 G-9�' l/ BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 MAILING ADDRESS for Health Pei-M t(If DIFFERENTfrom Facility Address) Attention orCare Of MAILING ADDRESS CITY STATE ZIP SIC CODE: APN#: ;LOC Z COMMENT: A—CCOUA[L DRES&for fees and charges: OWNER ❑ FACILITY/BUSINESS ❑ Rn.I.INc. AND COMPI.IANCF ACKNOWI.FDGMFNT: 1, the undersigned Applicant, certify that I am the Owner, Operator, or Authorized Agent of this Business, and I acknowledge that all PERMIT FSEs, PENALT/ES, ENFORCEMENT CHARGF_S and/or HOURLY CHARGES associated with this operation will be billed to me at the address identified above as the AccouNTADDREs,c 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 Re ulations. APPLICANT NAME:16 SIGNATURE: Please Print TITLE: DATE DRIVER'S LICENSE# Approved By Date Accounting Office Processing Completed By Date 3 kA' 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 10/9/2003