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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> SHADED SECTIONS FOR EHD USE ONLY OWNERID# ao610 aa. g70 CASE# -� <br /> OWNER FILE <br /> COMPLETE THEFOLLOW/NG BUSINESS OWNER INFORMATION: CHECK/F OWNER CURRENTLYONFiLEWiTHEHD❑ <br /> BUSINESSI <br /> > <br /> OWNER'S NAME /G� E7L`a' <br /> First MI Last <br /> BUSINESS NAME(If d/ffemnt(romOwner Name) Soc Sec OrTax ID# <br /> (DO it7 Jci./ i© f'.G <br /> OWNER'S HOME ADDRESS <br /> CITY�p STA 5-1 ZIP QS" <br /> OWNER'S MAILING ADDRESS (If different from Owner's Address) Attention orCare of <br /> Z-3,35)) CAC1� / <br /> rf�ft/n�lF� W SUiT�'� .�.ylc7i �or� G�1ir7�/C�c''t <br /> MAILING ADDRESS CITY <br /> TYPE OF OWNERSHIP: <br /> CORPORATION' INDIVIDUAL[I PARTNERSHIP El LOCAL AGENCY❑ COUNTYAGENCY❑ STATE AGENCY El FED AGENCY OTHER❑ <br /> FACILITY FILE <br /> FACIUTYID#: &Wat-f30 7 CO-OWNER ID#: <br /> AccouNr ID#:��jb/✓f$Z <br /> COMPLETE THEFOLLOW/NG BUSINESS FACILITY INFORMATION.' <br /> Is this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES NO ❑ <br /> . Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ❑ <br /> BUSINESS/FACILITY NAME(This will b the SUSINESBNAMEOn the HEALTH PERMIT) <br /> /�/9 l /C, �fi <br /> FACILITY ADDRESS(if FAcnnvla a MOSILEFOOD UNITor FOOD PEH/CLEUSO the COMMISSARY ADDRESS) BUSINESS PHONE c39 <br /> 2/ g "V. w/1 0r l r,A/i9/ 607- r0l6 <br /> Suite# <br /> CITY(If FACILITYIs a MOSILEFOOD UNRor FOOD VEHICLE use the CoMMissARY Clryl STATE <br /> % n/ G✓/, 2 ILS- O <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY? KEY2 <br /> MAILING ADDRESS for Health Permlf(If O/FFERENTfrom Faci/ityAddress) Attention orCare Of _ <br /> ,_03? -nil7xG <br /> MAILING ADDRESS CITY /�70 f- / STATFn ZIP t--)� ,r <br /> SIC CODE: APN#: v COMMENT: `/-J >` <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 operation WIII be billed tome at the <br /> 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 <br /> all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or <br /> FEDERAL Laws and Regulations. <br /> APPLICANT'S NAME: /✓�J/� (/{/. / SIGNATU —�� - •' <br /> ! P/ease Print <br /> TITLE: X""��/�(1"�.�-.. DATE/v� DRIVER'S LICENSE# <br /> U Ay PHOTOCOPYREQUmED <br /> Approved By Date Accounting Office Processing Completed By Date /� i/�/-7 <br /> 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 <br /> except UST Program(Use SWRCB forms) <br /> EHD 48-02-035iL-OZ� R f w qO- //'7 ^/1 <br /> 8119/08 r•� / l�lJ- V Masterfile Record-Green <br />