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SAN JOA UIN COUNTY ENVIRONMENTAL HEALTH DEWRTMENT MASTERFILE RECORD INFORMATION FORM SHADED SECTIONS FOR EHD USE ONLY OWNER 10# CASE# OWNER FILE COMPLETE THEFOLLOwING BUSINESS OWNER INFORMATION. CHECK IF OWN ER CuRRENTL v oN FILE wtTH EH 0❑ BUSINESSS PHONE: OWNER'S NAME Fust MI Last QLISINESS NAM (If different from Own ame) SoC Sec orTax ID# SWILAUNLA OWNER'S HOME ADDRESS L= W, CITY S ZI W 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#: CO-OWNER ID#: ACCOUNT ID#: COMPLETETHEFOLLOwING BUSINESS FACILITY/NFORMATION.- 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 ❑❑� BUSIN SS/FACILITY NAME(This will be the BUSINEBSNAuEon the HEALTH PERMIT) FACILITY ADDRESS(If FActurvls a MOBlLEFOOD UNITOr F000 VEHicceuse the COMMISSARY ADDRESS) W BUSINESS PHONE VV '° W�Street Alumbnr - C ` X - q Suite# Ci ITY(If FACILITY Is a MOBILE FOOD UNIT o r FOOD VEHICLE u s e the COM M I ssARY CIN) STATE ZIPp _ BOARD OF SUPERVISOR DISTRICT :::LOCATION CODE KEY1 KEY2 W MAILING ADDRESS forHea/th Perm/t(If D/FFERENTfrom facility Address) Attention orCare jG, CQ LQ. I U-1 ' 16n 10V , MAI ADD ESS CITY ST TE G Zn J�� SIC CODE: APN#:I -� U !v� COMMENT: ACCOUNTADDRESS 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 will 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 and/or Standards and STATE and/or FEDERAL Laws and Regulations. APPLICANT'S NAME: C.�'t Y`^' SIGNATURE: Ple- e Grin1 r±,� TITLE: �r � DATE (.� DRIVER'S LICENSE 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 mut 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