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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM SHADED SEC77ONS FOR EHD USE ONLY p OWNER ID# D DD,' 3,2 I CASE# OWNER FILE COMPLETE THE FOLLOW/NG BUSINESS OWNER INFORMATION: CHECK IF OWNER CuwRENn v ou an c wires EHnI—I BUSINESS G fl FACILITY ADDRESS! (if FAC/Lf is a NosnxEFDOO UNfror FOOD VEHICLEuee the COMMISSARY ADORES S) spire # PHONE: OWNER'S NAME 'F STATE ZIP BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 First KEY2 MI I last r /L MAILING ADDRESS CITY Sa— BUSINESS NAME (If d/fferentfromOwner Name ZIP SIC CODE: APN #: Soc Seo OrTax ID # 6. 4161 G,. 04 Tq FACILITY/BUSINESS OWNER'S HOME ADDRESS f7 Oh✓tt� (.-!�� fe— IfJC� t CITY N r o STYTE C -a ` 3 0 OWNER'S MAILING ADDRE S (If different from Owner's Address) Attention orCare of Spot -4t-- LMAILING MAILINGADDRESS CITY STATE ZIP Ir't-`e TYPE OF OWNERSHIP: CORPORATION ❑ INDIVIDUAL ❑ PARTNERSHIP ❑ LOCAL AGENCY X COUNTYAGENCY ❑ STATE AGENCY ❑ FEo AGENCY OTHER ❑ FACILITY FILE FACILItt ID#: O CO-OWNERID#: ACCOUNTID#: AFOC 44,45o COMPLETE THE FOLLOW/NG BUSINESS FACILITY INFORMAT/ON: IS this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES ja NO ❑ Is this an ExiSTING Business LOCATION but a NEW TYPE of regulated Business? YES R' NO ❑ BUSINESS/FACILITY NAME (This will be the BUSINESS NAMEon the HEALTH PERMIT) FACILITY ADDRESS! (if FAC/Lf is a NosnxEFDOO UNfror FOOD VEHICLEuee the COMMISSARY ADORES S) spire # BUSINESS PHONE CITY (If FAciums a MOBILE FOOD UNIT or FOOD VEHICLE use the COMM ISSARY CIN) STATE ZIP BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 MAILING ADDRESS for Health Permit(If DIFFERENTfrom FacifftyAddmss) Attention or Care Of / G kq b r /L MAILING ADDRESS CITY Sa— STATE ZIP SIC CODE: APN #: COMMENT: ACCOUAfTADDRESS for fees and charges: OWNER ❑ FACILITY/BUSINESS BILLING AND COMPLIANCE ACKNOWLEDGMENT: [,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 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 n SIGNATURE: TITLE: /Y rt /.11 l N /- DATE r-�CJ� �i' VER'S LICENSE # PBOTOCOPYREOUIREDi Approved sy Date 11 Accounting Office Processing Completed By Ib I Dais �/ r/ 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 except UST Program (Use SWRCB forms) EHD 48-02-035 Masterfile Record -Green 81'19108