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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM SHADED SECTIONS FOREHD USE ONLY OWNER ID# CASE# OWNER FILE COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION: CHECK IF OWNER CURRENTLY ON FILE WITH EHD❑ BUSINESS PHONE: OWNER'S NAME First MI Last BUSINESS ^NAME(if different from Owner Name) p ( �j ' 1 SOC See or Tax ID# S0.w oc �:, Ca � � AQw4 nis }v Tic. yu.ld+ LL OWNER'S HOME ADDRESS IToa CITY d G ,'._C-,, S T ZIP 9S Z 0 OWNER'S MAILING ADDRESS (if different from Owner's Address) Attention or Care of T MAILING ADDRESS CITY STATE ZIP TYPE OF OWNERSHIP: CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY 14 STATE AGENCY❑ FED AGENCY OTHER❑ FACILITY FILE Cr P-$10 10 5 F FACILITY ID#: CO-OWNER ID#: ACCOUNT ID#' COMPLETE THE FOLLOWING BUSINESS FACILITY INFORMATION: IS this a NEW Business LOCATION or VEHICLE not preVIOUSIy regulated by the ENVIRONMENTAL HEALTH YES NO ❑ nom.,.er..�.,ro Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES NO BUSINESSIFACILITY NAME(This will be the BUSINESS NAMEon the H,YEAj�,TH PERMIT) 4 SOG `(n L rTIX W.i✓l.f �-/`�.� r ON. 3 qtr l t✓L FACILITY ADD SS(if Fc-may is a MOBILE FOOD UNITOr FOOD VfHiCUF use the COMMISSARY ADDRESS) BUSINESS PHONE 't If .S c.-'* TcxtLS�Y.._i..-, �$''� Suite# 2oori CITY(if FACILITY IS a MOBILE FOOD UNIT or FOOD VEHICLE use the COMMISSARY CITY) STATE ZIP BOARD OF SUPERVISOR DISTRICT LOCATION CODE Sk_j-a KEY1 KEY2 MAILING ADDRESS for Health Permit(If DIFFERENTfrom Facility Address) Attention or Care Of MAILING ADDRESS CITY STATE ZIP SIC CODE: APN#: /�// fq v I COMMENT: ACCOUNT ADDRESS 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 to me at the address identified above as the ACCOUNT ADDRESS 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 8y • Data / Accounting Once Processing Completed By Date y/ 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 8/19/08