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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM SHADED SECRONSFOR EHD USEONLY OWNER FILE COMPLETE THEFOLLOWINGBUSINESS OWNER INFORMATION: CHECKlF OWNER CURRENTLYOM FILE WITHEHD❑ BUSINESS � T PHO E: OWNER'S NAME . FfrsfM1 Last BUSINESS NAME If d' rent rom0 ner me) r(44�7 OC Sec r ID 16 77 OWNER'S HOME ADDREL U CITY S ZIP OWNER'S MAILING ADDRESS (If different from Owner's Address) Attention orCare of MAILING ADDRESS CITY STATE ZIP TYPE OF OWNERSHIP: CORPORATION❑ INDIVIDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY OTHER❑ FACILITY FILE FACILITY ID #,. WNER ID#E: ACCOUNT ID#: Q DQ 8 COMPLETE THE FOLLOWING BUSINESS FACILITY INFORMATION.' IS this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES IV NO ❑ IS this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ NO BUSIN S !FACILITY AM (L € will be a 6u 1NEssNa on th HEALTH PERMIT) FACIL TY ADDRESS(If FacrL7TYis aDir OsrcEFoon LNrrar Foo VExrc .Se t�COMMI Rr ADDRESS}. BUSINESS PHONE q,!A,_b&r j 111 I�/!!j Street Typ� Suite# �f CITY(1 a IYYI a MOBILE FOOD UNIT Or FOOD VEHICLE use the COMMISSARY CITY) STATE^/} ZIP BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 + KEY2 MAILING ADDRESS for Health Permflf(If DIFFERENTfrom Facility Address) Attention orCare Of MAILING ADDRESS CITY STATE ZIP SIC CODE: APN#: COMMENT: ACCOUNTADDRE$S 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 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. 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 and/or Standards and STATE andlor FEDERAL Laws and Regulations. , APPLICANT'S NAME: SIGNATURE: J//n1 / Please Print TITLE' 1'J //I DATE DRIVER'S LICENSE# e4 •► 117 PHOTOCOPY REQUIRED Approved By Date - Accounting Office Processing 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 Masterfife Record-Green 81'I9108