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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DE`Pr4_ RTMENT MASTERFILE RECORD INFORMATION FORM SHADED SECTIONS FOR END USE ONLY OWNER 10# CASE# OWNER FILE COMPLETE THE FOLL\OBUSINESWING BU SI N ESS OW N E R/NFORMATION.- CHECK IF OW N ER CuRRENTL r oN Fli E wiTH EH D❑ OWNER'S NAME r %_A.— PHONE: First MI last BUSINESS NAME(If diNeren f(om Owner Name) _ SOC Sec or Tax ID# OWNER'S HOME ADDRESS CITY ST ZI � 7 1 OWNER'S MAILING ADDRESS(If different from Owner's Address) Attention orCare of Cil) MAILING ADDRESS CITY STATE ZIP TYPE OF OWNERSHIP: CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ FACILITY FILE FACILITY ID#: CO-OWNER ID#: ACCOUNT ID#: COMPLETE THE FOLLOWING 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 INES �FACi NAME(This will be M SUSINESSNAM£Oe H LTR PERMIT) Lk__ FACILITY ADDRESS(If Facl[�S a MOB/LEF000 UN/ror FOOD L�Euse,the COMMISSARY ADDRESS) BUSINESS PHONE St,,,tM,mh ��///��Il�1Yr�^W./' WA Suite# (moi (If FAMOBILE FOOD UNITOr FOOD VEHICLE USe the COMMISSARY CIN) S14TE ZIP BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 MAILING ADDRESS AbrL�eA�7 Pe%/7Nt(If OIFFERENTfronf'Faci/ityA ressJ� Attention orCare , T �2 p t I"'`Nil N. D Crt�y STATE ziPT 14 SIC CODE: APN#: LL COMMENT: J ACCOUNTADDRESSfor fees and charges: OWNER ❑ FACILITY/BUSINESS ❑ BILLING AND COMPLIANCE ACKNOWLEDGMENT: [,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. VV APPLICANT'S NAME: Y J� � L M SIGNATURE: lease Print ' Ij TITLE DATE 2�J� PHOTO HO R COPCEREO NSE,RED Approved By Date Accounting Office Processing Completed By Date II A PROGRAM{EHD 48-02-034 Pink) or WATER SYSTEM(EHD 46-02-0031 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 11/27/07