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SAN JC,JIN COUNTY ENVIRONMENTAL HEALTH L...�ARTMENT MASTERFILE RECORD INFORMATION FORM SHADED SECTIONS FOR EHD USE ONLY OWNER ID# G1 V/ I / CASE# (� `COWNER FILE COMPLETE THEFOLLOW/NG BUSINESS OWNER INFORMATION: CHECK IF O W NER CURRENn YON FILE wiTHEHD❑ BUSINESS C tI:iPHONE: OWNER'S NAME Last av9- yea-78��0 First MI BUSINESS NAME(If different fmmOwner Nam.) Soo Sec orTax ID# -r 55<1- �1 - 4958 OWNER'S HOME ADDRESS '135 Ft e ' [7 - CITY 1 ade 111 E ZIP _IQ5 OWNER'S MAILING ADDRESS (If different From Ownees Address) Attention orCare of r'DID :,c lr.31) gsa3lo MAILING ADDRESS CITY I I TE ZIP TYPEOFOWNERSHIP: �-•1 CORPORATION❑ INDIVIDUA PARTNERSHIP❑ LOCALAGENCY❑ COUNTYAGENCY❑ STATE AGENCY❑ FED AGENCY[:1 OTHER❑ FACILITY FILE FACILITYID#: p2 CO-OWNER ID#: ACCOUNTID#: COMPLETE THEFOLLOW/NG BUSINESS FACILITY INFORMATION- �yI L Is this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ICNO ❑ Is this an ExISTING Business LOCATION but a NEW TYPE Of regulated Business? YES E] No IAI BUSINESS/FACILITY NAME(This will be the BUS/NESSHAMEOn the HEALTH PERMIT)r`B ^ N�Q S FACILITY ADDRES "FACILrrTisa MOaILEF000 UN?or F000✓EHCLEuse the COMMISSAR Y ADDRESS) ' , ••.) BUSINESS PHONE 735 1 N.��tne suite# .1:2D?- �8a-'7 (0 C (If FACLITY Is a MOBILE FOOL UHrror FOOO VEHICLE use the COMMISSARY CRY) ry-TTE ZIP /?d/T3 to BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 MAI ADDRESS rhealth Permll(If O/FFERENTfrom FacilityAddress) 7AH..tion orCare O/ I U ox, �a3L) MAILING ADDRESS CITY LinAe rn STATE �I Q zip 95ps SIC CODE: APN MCOMMENT. COMMEN ACCOUNTADORE88 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 WIII be billed to me at the address identified above as the ACCOUNTADORESS 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 or Stand;0 and STATE and/or FEDERAL Laws and Regulations. APPLICANT'S NAME: a� F OJIIN SIGNATUR P/ease Print DATE 511,2 114 DRIVER'S LI SE _3aa0g17 0TITLE: Q tJ PHOTOCOP EQUIREO Approved By C Oafs Accounting Office Processing Completed By Date A PROGRAM(EHD 48-02-034 Pink)or WATER YSTEM EH 46-02-003)form must be completed for each EHD regulated operation at this LOCATION except UST Program(Use SW RCB forms) Masterfile Record-Green EHD 48-02-035 11/27/07