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SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM SHADED SECTIONS FDR EHD USE ONLY DWNER ID# b0,1)02CASE# OWNER FILE COMPLETE THE FOLLOW/NG BUSINESS OWNER /NFORMAT/ON: CNEctc AF OWNER CuRRENTL v ON FILE wiTH EH D❑ BUSINESSn�I C PHONE: OWNER'S NAME / — ' )L `��',N� G L C� First MI Last zD f —� BUSINESS NAME(If different from Owner Name) Soc Sec or Tax ID# OWNER'S HOME ADDRESS (j 3`b_i� 1 'j l✓�¢. cls CITY oTATE ZIP IiEJ C OWNER'S MAILING ADDRESS (If different from Owner's Address) Attention or Care of MAILING ADDRESS CITY STATE zip TYPE OF OWNERSHIP: CORPORATION INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY OTHER❑ FACILITY FILE r� p FACILITYID#: d2—sol OUN CD-OWNER ID ACCTID#: r«.00L�yzy COMPLETETHEFOLLOW/NG BUSINESS FACILITY 1NFORMAnoN. Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES No ❑ neo.er..�.ro Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ❑ BUSINESS/FACILITY NAME(This will be the BuslNEss NAMEOn the HEALTH PERMIT) 1UNlror FooD✓EHrcLr cOsG FACILITY ADDRESS(If FACILIYis a MOBILE FOOD Ee the COMMISSARY ADDRESS) BUSINESS PHONE 163�6_q iv fel 1-2c)1.10 *2 DC(-3�s Suite# CITY(if FACILITYIs a MOBILE FOOD UNIT or FOOD VEHICLE use the COMMISSARY CIT,') STATE ZIP o cQ GA q S BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEYI KEY2 MAILING ADDRESS for Health Perm/t(lf D/FFERENTfrom Facility Address) Attention or Care Of MAILING ADDRESS CITY STATE ZIP I SICCODE: APN#: (rj S/— p'7p COMMENT: ACCOUNTADDRESS for fees and charges: OWNER ❑ FACILITY/BUSINES�I 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 Operation will be billed to me at the 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 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 Regulations. APPLICANT'S NAME: SIGNATURE: Please Print TITLE: DATE DRIVER'S LICENSE# PHOTOCOPY REQUIRED Approved By Oate AccaunBng Office Proceaeing Completed By Data 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) ,�n EHD 48-02-035 CV j / p J� Masterfile Record-Green 8119/08 O( (/