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SAN JC N COUNTY ENVIRONMENTAL HEALT ]SION OWNER• FACILITY*ACCOUNT MASTERFILE RECO INFORMATION FORM (EH 0015REwsED81211999) SHADED SECTIONS FOR EHD USE ONLY OWNER ID# OW CASE# OW OWNER FILE COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION: CHECKIF OWNER CURRENTLY ON FILE WITH EHD d4f BUSINESS /�—/� /�J ��'I /J �; PHONE OWNER NAME y l J BUSINESS NAME(If different from Owner Name) /'" SOC Sec Or ax ID, OWNER HOME ADDRESS ,n el /� Driver's License# CITY STATE ZIP OINt��R MAILING ADDRESS (If different from Owner Address) Attention or Care of MAILING A DRESS CITY STAT ZIP /� TYPE OF OWNERSHIP: CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ FACILITY FILE FACILITY ID#: FA OWNER ID#: OW ACCOUNT ID#:AR CO-OWNER ID#: OW COMPLETE THE FOLLOWING BUSINESS FACILITYINFORMATION: IS this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DIVISION? YES ❑ NO ❑ IS this,an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ NO ❑ S ESS/F,AC�IL AME his w I qe the Bu s NA�eon the 'VI 1 TH PERMIT) FACILI TY ADD}2E_SS_(if FACILITY i�MOBILE FOOD UNlrgr,oO VVEHI�the COMMISSARY ADDRESS BUSINESS PHONE Number Direction Iw( //VAI, Sfreet Name Street Type Suite# CITY(If ACILITYIs a MOBILE FOOD UNITor FOOD VEHICLE use the COMMISSARY CITY) STATEA ZIP BOARD OF SUPERVISOR ISTRICT LOCATION CODE KEY? (/ KEY2 MAILIA19ADDRES for Health Permit(if DIFFERENT from Facility Address) Attention or Care Of O� MAILING A SS CI Y STATE ZIP �](40 SIC CODE: APN#: COMMENT: ` THIRD PARTY BILLING INFORMATION• Complete if Billing Party is different from Business Owner Identified above. BUSINESS NAME Attention or Care Of MAILING ADDRESS PHONE CITY STATE ZIP T70U7ACCOUNT ADDRESS for fees and charges: OWNER FACILITY/BUSINESS❑ THIRD PARTY BILLING❑ 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 PERNHTFEES,PENALTIES,ENFORCEMENT CHARGES and/or HOURLYCHARGES associated with this operation will be billed to me at the address identified above as the ACCOUNT ADDRESS 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 NAME: SIGNATURE: Please Pnnt Approved By Date Accounting Office Processing Completed By Date A PROGRAM (EH 0069 Pink)or WATER SYSTEM (EH 0069 Blue)form must be completed for each EHD regulated operation at this LOCATION except UST Program(Use SWRCB forms) EH 0015 MFR Green Form.DOC