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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM SHADED SECTIONS FOR EHD USE ONLY OWNER ID# .'z3�L� CASE# �I I to � C_ OWNER FILE COMPLETE THE FOLLOw/NG BUSINESS OWN ER/NFORMAT/ON-' CNEcKIF OWNER CuRRENTtYoNF1LEwtTHEHD❑ BUSINESS PHONE: OWNER'S NAME First MI Lasf f differentpfram ner Name) Sac Sec or Tax D# L� OWNER'S HOME ADDRES82 CITY ZIP OWNER'S MAILING ADDRESS (If different from Owner's Address) Attention or Care of MAILING ADDRESS CITY STATE ZIP TYPE OF OWNERSHIP: CORPORATION❑ INDIVIDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY OTHER❑ FACILITY FILE FACILITYID#: 66ro .Z!Y- 3 CO-OWNERID#: ACCOUNT ID#: COMPLETE THEFOLLOwfNGBUSINESS FACILITY/NFORMAT/ON: Is 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 ❑ BUS ESS/FACILITY NAME(Thi will be the USI ESS NAMEon the HEALTH PERMIT) FACILITY ADDRESS(If FAcxl rie aMo ILEFOOD N/ FOOD VEH/CLEYS PS COMMISSARY ADDRESS) BUSINESS PHONE 0UL 6Y "7 UCSuite# Q / 2)1]ME OBILE FOOD UNIT Or FOOD VEHICLE use the COMMISSARY CITY) .STAT ZI ft BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEYI ce KEY2 MAILING ADDRESS for Heath Permit(If D/FFERENTfrom F, 'Vt Address) Attention or Care Of MAILING DRES CISTA ZIP t�r SIC CODE: APN#: COMMENT: ACCOUNTADDRESS 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 Will be billed to me at the address identified above as the ACCOUNT AoDRE33 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: Ica 12 18 V I K CaftA61 SIGNATURE: Please Print - TITLE: DATE DRIVER'SLICENS E# PHOTOCOPY REQUIRED Approved By Deb Accounting Office Processing Completed By / LL OW OLS/2 f� A PROGRAM{EHD 48-02-034 Pink)or WATER SYSTEM(EHD 48-02-003)form must be completed for each EHD regulated operation at this LOCATION except UST Program(Use SWRCB forms) EHD 48-02-035 / /� 01 Ct ` / (0, t/ /" C O yastr/' le Record-Green 8119108