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SAN JOAI IIN COUNTY ENVIRONMENTAL HEALTH PARTMENT ISTERFILE RECORD INFORMATION FA SHADED SECTIONS FOR EHD USE ONLY OWNER ID# W00a4 b CASE#- OWNER FILE 1 COMPLETE THEFOLLOw/NG BUSINESS OWNER/NFORMAT/ON: CHEcN iF OWNER CuttRENTtYON FILE wiTHEHD❑ BUSINESS -IIONE: OWNER'S NAME mar '�' q 3/-_74 FI f MI Las BUSINESS NAME(If different from Owner Name) SOC SBC or Tax ID# OWNER'S HOME ADDRESS 5 vIJ CITY / f,/t STATE zip OWNER'S MAILINGADDRESS (if-diHerentlfrom Owner's Address) Attention or Care of MAILING ADDRESS CITY STATE zip TYPE OF OWNERSHIP: CORPORATION❑ INDIVIDUAL El PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY F-1 STATE AGENCY El FED AGENCY OTHER❑ FACILITY FILE � FACILITYID#: VA 171 Its 1 CO.OWNER ID#: ACCOUNTID#_! :F,00 cla�t-� COMPLETE THEFOLLOw/NGBUSINESS FACILITY INFORMATION. Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES NO ❑ n�e.er..�...o Is this an ExISTING Business LOCATION but a NEIN TYPE of regulated Business? YES ❑ No BUSINESS/FACILITY NAME(This will be the BUSINESS NAMEon the HEALTH PERMIT) M I FACILITY ADDRESS(if FACIL619 a MOBILEFOOD N/ror FOOD VE11/CLEa9e the COMMISSARY ADDRESS) BUSINESS PHONE -2 6907 LA)AW00 (V' Suite# CITY(If FACILRYlS a MOBILE FooO UNrror FOOD VEHIctE use the COMMISSARY CITY) STATE zip ry 7 C// % �J BOARD OF SUPERVISOR DISTRICT 9 LOCATION CODE a KEYI KEY2 MAILING ADDRESS for Health Permft(If D/FFERENTfrom FaciiityAddress) Attention orCare Of MAILING ADDRESS CITY STATE zip SIC CODE: APN#: I_ — 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 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 FEDERAL Laws and Regulations. APPLICANT'S NAME: SIGNATURE: P/ease Print TITLE: DATE DRIVER'S LICENSE# PHOTOCOPY REQUIRED Approved By Date Accounting Office Proceeaing Completed By Date 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 8/19/08