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SAN JO.11IN COUNTY ENVIRONMENTAL HEALTH Ef--V1ENT MASTERFILE RECORD INFORMATION FORM SHADED Ste-rimsFOR EHD USE Oxy OWNER ID# � CASE# OWNER FILE COMPLETETHEFOLLOVYINGBUSIN ESS OWNED INFORMATION: CHIEcKiF OWNER CuRRENnY01VFrLEwtT.vEHD❑ BUSINESS r I N ��,!�� PHONE: OWNER'S NAME First rft Last BUSINESS NAME(If ditterent from Owner Name) oc orTax ID# OWNER'S HOME ADDRESS {j MYRCkUD An 2 LP CITYMCA y+CCr� 5 E Zip a 7� – 3 OWNER'S MAILING ADDRESS (If different from Owner's Address) Attention or Care of �3 J r MAILING ADDRESS CITY STATE ZIP TYPE Of OWNERSHIP; ,—]/, CORPORATION❑ INDIVIDUAL& PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ FACILITY FILE FACILITY ID#: 2 �t g4, CO-ONINER ID#: ACCOUNT ID#: COMPLETE THEFOLLOw/NG BUSINESS FACILITY INFORMATION.' Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES NO ❑ Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No BUSINESS/FACILITY NAME(This will be the$uSmEsSNAMEon the HEALTH PERMIT) a k G. 1 �LA FACILITY ADDRESS(tf FACILITis a 08ILEF000 Umror FOOD VeulcL9use the COMMISSARY ADDRESS] BUSINESS PHONE r 601 P `]'l Ie rk--)n d r. X22p L4/10StreelNumber Direction Streefftme T— Suite# i CITY(If FActuTrls a MOBILE FOOD UNrr or FOOD VEHICLE Use the CDMMBSARY CITY) STATE ZIP YY,I Ck n-�--Ecc, C1 5�� BOARD OF SUPERVISOR DISTRICT LOCATION CODE Kul KEY2 MAILING ADDRESS fOr Heaffh Permlf(lf DIFFERENTfrom Facility Address) Attention orCare Of MAILING ADDRESS CITY FTATE ZIP SIC CGDE: :AP7NA; COMMENT: ACCOUNTADDRESS for fees and charges: OWNER FACILITY/BUSINESS ❑ BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner,Operator,orAuthorizedAgent of this Business,and I acknowledge that all PERMIT FEES, PENALTIES,ENFORCEMENT CHARGES andlor HOURLY CHARGES associated with this operation Will be billed to me at the address identified above as the AccouNTADORESs for this site. 1 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 andlor Standards and STATE andlor FEDERAL Laws and Regulations. APPLICANT'S NAME: n d Ila r SIGNATUR . Please Print _ TITLE: / r '* � DA`? PHOTOCOPY R QUIR D Approved By Vv} Data j(� Accounting Office processing Completed By Date g 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 11127107