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SAN JOAQUIl" COUNTY ENVIRONMENTAL HEALTH DEPORTMENT MAwCERFILE RECORD INFORMATION FORM— SHADED SECTIONS FOR EHD USE ONLY OWNER ID# 0V � 0t`l 9! !1:21 J� CASE# V `/ / OWNER FILE (/ COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION: CHECK IF OWNER CURRENTLY ON FILE WITH EH BUSINESS PHONE: /' OWNER'S NAME 2 9 4 — 3 6 Firs/ MI Last BUSINESS NAME(If different from Owner Name) SOC SBC Or Tax ID# AMefILAN -COV,3 ✓f�_ / OWNER'S HOME ADDRESS o. I, b b 36 CITY I „ c, � STIIPEz ZIP 95"6 �3 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 FACILITY ID#: l a 13b CO-OWNER ID#: {{ ACCOUNT ID#: COMPLETE THE FOLLOWING BUSINESS FACILITY INFORMATION: L12( LQ OL( 06 Is this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES 161. NO ❑ nr•,,.eT..�.ro Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No f BUSINE S/IF iTY NAME(This will l>e the BUSINEss NAMEon the HEALTH P MIT) M e r`I A N e l - 4 �� FACILITY ADDRESS(If FACILITY is a MOBILE FOOD UNIT or FOOD VEHICLE use the ComMissARY ADDREss) BUSINESS PHONE 20-7L-I t S. SNF 2b• Suite 60 2� -D go CITY(If FACILITY IS a MOBILE FOOD UNIT or FOOD VEHICLE Use the COMMISSARY CITY) STALE ZIP S-36i N BOARD OF SUPERVISOR DISTRICT DO LOCATION CODE KEY1 KEY2 MAILING ADDRESS for l4ealth erR1/t(If DIFFERENTfrom Facility Address) Attention Or Care Of o . a X 3� b MAILING ADDRESS CITY 6,e N rl \< STATE ZIP S-0 q el SIC CODE: 1 2 2 a D So COMMENT: APN#� ACCOUNT ADDRESS for fees and charges: OWNER ❑ FACIUTYIBUSINESSlink BILLING AND COMPLIANCE ACKNOWLEDGMENT: ],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 11 Approved By V t/,/� Date- 127 1211 I 11 AceounOng Office Processing Completed By Date / A PROGRAM(EHD 48-IOP-034 Pink)or WATER SYSTEM(EHD 46-02-0031 form must be completed for each EHD regulated operation at thi4 LOCATION except UST Program(Use SWRCB forms) EHD48-02-035 Masterfile Record-Green 8/19/08