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SAN JOAQUINI COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MAsfERFILE RECORD INFORMATION FORM.i SHADED SECTIONS FOR EHD USE ONLY OWNERID# Dy — boo / 700 CASE# OWNER FILE COMPLETE THE FOLLOWING BUSI NESS OWNER INFORMATION: CHECK IF OWNER CURRENTLY ON FILE WITH EHD BUSINESS PHONE: /� OWNER'S NAME 6D2 2D _ 0290 Firsr MI Last BUSINESS NAME(If different from Owner Name) Soc Sac Or Tax ID# fel er ) GrXN Tow eu� OWNER'S HOME ADDRESS r D I & 76 0(1'(,/ CITY I q 6,0 N( �c ST TEZ ZIP Q Sv Q Z OWNER'S MAILING ADDRESS (if different from Owner's Address) Attention or Care of V v MAILING ADDRESS CITY STATE ZIP TYPE Or OWNERSHIP: - CORPORATION INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY OTHER❑ FACILITY FILE FACILITY ID#: CO-OWNER ID#: / T ACCOUNT ID#: COMPLETE THE FOLLOWING BUSINESS FACILITY INFORMATION: E IZ.1 1 D Q 6_7 U F this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES NO ❑.,. othis an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ NO I� BUSINESS/FACILITY NAME(TNis will be the 9U31NE93 NAMEOn the HEALTH PE NIT) M � I�a j VjeI- - e �ICip ' - f� 82537 FACILITY ADDRESS(If FACILITY IS a MOBILE FOOD UNITOr FOOD VEHICLE use the CommissARY ADoREss) BUSINESS PHONE Fre11�L C6M p Qh_street Number L. Suite 6o2 2QLf—b2bo CITY(if FAcnR is a MOBILE FOOD UNITor FOOD VEHICLE use the COMMISSARY CITY) STAT /� zip � �� M ht e L A /�/� A BOARD OF SUPERVISOR DISTRICT DD 3 LOCATION CODE 445/ KEY1 KEY2 MAILING ADDRESS for HEHIIILPCFIIIIt(lf D FERENTfrom Facility Add/ress)1 Attention or Care Of ' O . , 3� 0 MAILING ADDRESS CITY p Iv1rs e r`I \N STATE /� -2- ZIP SIC CODE: f APPNp: � © I COMMENT: ACCOUNTADDRESS for fees and charges: OWNER ❑ FACILITY/BUSINESS 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 WIII be billed t0 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# ppp PHOTOCOPY REQUIRED 11 Approved By (Z Date I 9 3 12 Accounting Oce Processing Completed By Date A PROGRAM(EHD 4V8-1022-034 Pink)or WATER/SSYSTEM.(JOfficeEHD 46-02-003)form must be completed for each EHD regulated operation A this LOCATION except UST Program(Use SWRCB forms) EHD 48-02-035 Masterfile Record-Green 8/19/08