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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM SHADED SECTIONS FOR EHD USE ONLY �NER ID# 91000 .2.2-gL (, CASE# OWNER FILE J COMPLETE THE FOLLOW/NG BUSINESS OW IN ER INFORMATION: CHECK IF OWNER CURRENTLYON FILE wirH EHDEI BUSINESS PHONE: OWNER'S NAME First I MI I Last BU INESS NAME(If di/fe t from Owner ame) Soo Sec orTax ID# CA a — e OWNER'S HOME ADDRESS CITY STATE ZIP OWNER'S MAILING ADDRESS (If different from Owner's Address) Attention orCare of MAILING ADDRESS CITY STATE ZIP TYPEOFOWNERSHIP: CORPORATION INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY OTHER❑ FACILITY FILE �y FACILITYID#: FAX 21q CO-OWNERID#: ACCOUNTID#: DD�J�Z�JS COMPLETE THE FOLLOWING BUSINESS FACILITY INFORMATION.' OC I,,_,r 13 this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES NO ❑ Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ NO ❑ BUSINESS/F CILITY NAM (This will b the EUS/NESS NAMED n the HEALTH PERMIT) algan Z CT FACILITY ADDRES (If FAcwTrls OaILEFOOD UNITor FOOD VEHimEuse the COMMISSARY ADDRESS) �/BUSINESS PHONE Z'll viae' `�-� Sufte# CITY(IfFACanYls a MosaEFOOD UNRor FOOD VEHICLE use the COMMISSARY CITv) STATE zip o \ G BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 MAILING ADDRESS for Health Permt(If OIFFERENTfrom Facl/ltyAddress) Attention orCare Of ie r l MAILINGESS I p I STATE ci `1 ZIP ! Mnl1. SIC CODE: APN#: COMMENT: ACCOUNTADORESS for fees and charges: OWNER ❑ FACILITY/BUSINESS ❑ BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and 1 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: GATE DRIVER'S LICENSE# PHOTOCOPY REQUIRED Approved ay DW Accounting Office Processing Campleted By Date /,g 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 LOCA/TION except UST Program(Use SWRCB forms) EHD 48-02-035 Masterfile Record-Green 8119/08