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SAN aJOAVUIN COUNTY ENVIRONMENTAL HEALTH DEWRTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> SHADED SECTIONS FOR EHD USE ONLY OWNER ID# CASE# <br /> OWNER FILE <br /> COMPLETE THEFOLLOW/NGBU NESS OWNER/NFORMAT/ON.' CHECK/FOWNER CURRENTLYONF/LEW/THEHD❑ <br /> BUSINESSPHONE: <br /> OWNER'S NAME c* I�TzftAby_� <br /> First MI Last <br /> BUSINESS NAME(If different from Owner Name) Soo Sec orTax ID# <br /> OWNER'S HOME ADDRESS !34111� o/, C_W� <br /> CITY ZIP <br /> OWNER'S MAILING ADDRESS(If different from Owner's Address) Attention orCare of <br /> MAILING ADDRESS CITY STATE zip <br /> TYPE OF OWNERSHIP: <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID#: CO-OWNER ID#: ACCOUNT ID#: <br /> COMPLETETHEFOLLOW/NG BUSINESS FACILITY/NFORMAT/OAV <br /> Is this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO <br /> Is this an EXISTING Business LOCATION but a NEwTYPE of regulated Business? YES ❑ N <br /> (NESS/FACIINAME(This will be^e BUSINESON.AMEOHELTHQERMIT)� <br /> jN— <br /> FACILITY <br /> ADDRESS(If FAc/L/TYIs a MosILEFOOD UN?or FOOD VEHIOLEuse the COMMISSARY ADDRESS) " BUSINESS PHONE <br /> l9� `I= <br /> Suite# <br /> CITY(IfFACILJTYI$ MOBILE FOOD UNIT orFOODVEHicLEusethe COMMISSARYCIiY) STATE ZIP <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE TKEY1 KEY2 <br /> MAILING AD ESS forHealfh T_=�= <br /> Addr Att ntion r re <br /> ` <br /> ILA CI Y zl ,�;&' <br /> SIC CODE: APN M. ` �' —�LA COMMENT: <br /> SS-for fees and charges: OWNER ❑ FACILITY/BUSINESS <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I <br /> acknowledge that all PERMIT FEES, PENALTIES, ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation will be billed to me at the <br /> 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 <br /> regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or FEDERAL <br /> Laws and Regulations. <br /> APPLICANT'S NAME: {I ' '��-� vCJ v` SIGNATURE: <br /> /e Print. ORIVER <br /> TITLE: ��A DATE <br /> �v 1 ' PHOTOCOPY REQUIRED) <br /> TITLE: DATE ERIS LICENSE# <br /> E UIREDISLICENSE# <br /> Approved By Date Accounting Office Processing Completed By Date <br /> 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 <br /> except UST Program(Use SWRCB forms) <br /> EHD 48-02-035 Masterfile Record Green <br /> 11/27/07 <br />