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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> SHADED SECTIONS FOR EHD USE ONLY OWNERID# `0II IOT� <br /> OWNER FILE <br /> COMPLETE THEFOLLOM7NG BUSINESS OWNER/NFORMAT/ON: CHECK IF OWNER CURRENTL v ON Fit E w/TH EHD❑ <br /> BUSINESS <br /> OWNER'S NAME ��/ PHO E: <br /> First IMI Last 2Cq ow en C- <br /> BUSINESS NAME <br /> (If different from Owner N me) Soc Sec arra%ID# <br /> (v, rN <br /> OWNER'S HOME ADDRESS a 1 rP 0�� <br /> CITY -'r S Vex ZIP <br /> OWNER'S MAILING ADDRE9 (If different/ram Owner's dreas) Attention or Care of <br /> MAILING ADDRESS CITY 4J 4 �^ E ZIM <br /> TYPE OF OWNERSHIP: `'I <br /> CORPORATION INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID#: �'.Z 3 CO-OWNER ID#: <br /> ACCOUNT ID#: <br /> COMPLETE THEFOLLOW/NG BUSINESS FACILITY/NFORMAT/ON.' <br /> Is this a NEW Business LOCATION Or VEHICLE not Previously regulated by the ENVIRONMENTAL HEALTH YES NO ❑ <br /> n...o...�.r.•a <br /> Is this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ NO ❑ <br /> BUSINESS/FAgILTry NAME(This will be a BUSINESSNAMEon IP6 HEALTH PERMMn <br /> FACILITY ADDRESS(If FgciL/rri aMoe!{EFooD UNrror FOODVENIC aethe COMMISSAR ooREss 1_ � BUSINESS P'HIONE <br /> w <br /> ��Ds 0 \ t/.tnYV\ U�1\ 1. O suite u G— 12 Zcil <br /> CITY(If FAaurvls a MOBILE FOOD UNITor FOOD VEHICLE use the COMMISSARY CQTv) STATE Zip <br /> CA <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> MAILING ADDRESS for Health PerMit(If D/FFERENTfroin Facility A ddress) Attention or Care Of <br /> MAILING ADDRESS CITY STATE ZIP <br /> SIC CODE: APN#: COMMENT: <br /> ACCOUNTADDRESS for fees and charges: OWNER ❑ FACILITY/BUSINESS ❑ <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: i,the undersigned Applicant,certify that I am the Owner, Operator,or Authorized Agent of this Business,and <br /> I acknowledge that all PERMIT FEES,PENALTIES,ENFORCEMENT CHARGES and/Or HOURLY CHARGES associated With this operatlo will be billed to me at the <br /> address identified above as the ACCOUNTADCREss for this site. I also certify that all information provided on this applicatio Is true and c ect;and that <br /> all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COU NTv Ordinance Codes nd/ ' Standards a d9,ATE and/or <br /> FEDERAL Laws and Regulations. <br /> APPLICANT'S NAME:l 1 \C���Y ' {, ` \GG�L(J SIGNATURE: <br /> C / 1 <br /> TITLE: Please Print <br /> `/ DATE '1 lV ''t DRIVER'S LICENSE# f1 Glt _(.� <br /> 1 PHOTOCOPY REQUIRED IBJ lY <br /> Approved By Date Accounting office Processing completetl By D.W <br /> A PROGRAM(EHD 48-02-034 Pink)or WATER SYSTEM{EHD 46-02-0031 form must be completed for each EHD regulated operation at this LOCATION <br /> except UST Program(Use SWRCB forms) <br /> EHD 48-02-035 <br /> 811 9/08 Masterfile Record-Green <br />