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leae SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM SHADED SEC77ONSFOREHD USE ONLY OWNERID# 191 CASE# OWNER FILE COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION: CHECKIF OWNER CURRENTLY ON FILE KITH EHD BUSINESS PHONE OWNER NAME 3-UV— 9%a—v6 S First MI Last 5 BUSINESS NAME(if different from Owner Name) Sue See or Tax ID# - sz"" et f OWNER Hate} C') C, CITY S+,Or _ STATE Z!P S b y OWNER MAILING ADDRESS (If cutwent eom Own"Address) Attention,w`Care of n MAILING ADDRESS CITY STATE LP TYPE OF OWNERSHIP: CORPORATION❑ INDMDUAL❑ PARTNERSHIP❑ LOCAL AGENCY COUNTYAGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ FACILITY FILE FACWTY ID#: Q' CO-OWNERID#: ACCOUNT ID#: COMPLETE THE FOLLOWING BUSINESS FACILITY INFORMATION: CLsrR—� I D /D Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO ❑ Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ❑ BUSINESS/FACILITY NAME(Thiswil be the BUSINEssNAMEOn the HEALTH PERMIT, , n 'S�a�,u;� FACILITY ADDRESS(IfFAaurY is a MositeFOOD U Nor FooD VEVWLEUSO the COMM, c ADCFFgcl BUSINESS PHONE / ?-7 s5 N • T-V) (Z Suite# CITY(if FACU7ve;a MmLs FOOD UMror FOOD YEMceeme the CDraeeswwC r) STATE LP o �; L14 Sa y2 BOARD OF SUPERVISOR DISTRICT Z'L I LOCATION CODE KEY? KEY2 MAW NG ADDRESS for Health Perrnit(If DIFFERENT from Faality Address) Attention orCare Of —7-75'1 LJa EdQ,z lucckes.' MAILING ADDRESS CITY C \ r\ STATE / ^ ]Jp SIC CODE: APN#: Q SS(3 D I Co. ACCOUNT AnnRFCC for fees and charges: OWNER ❑ FACILITY/BUSINESS 1� Biiij Nf: AND CUMPl rANcr ACKNowr PI fMFNT; I, the undersigned Applicant, certify that I am the Owner, Operator, or Authorized Agent of this Business,and I acknowledge that all/HERMIT FEES,PENALTIES,ENFORCEMENT CHARGES and/Or F/OURLY CHARGES associated with this operation will be billed to me at the address identified above as the AcennNTAnnxEcc for this site. 1 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 F`EDEaAL Laws and Regulations. APPLICANT NAME: J OYS✓I � t SIGNATURE: Please PrintL/ TITLE: �.S S.� t/ DATE ` / / DRIVER'S LICENSE Approved By Date Accounting Office Processing Completed By Date A PROGRAM(EHD 48-02-034 Pink)or WATER SYSTEM(EHD 46-02-003)Torn most be completed for each EHD regulated operation at this Xec.pt UST Program(Use SWRCB forms) EHD 48-02-035 10/9/2003 Masterfile Record-Green