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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DERTMENT MASTERFILE RECORD INFORMATION FORM SHADED SECTIONS FOR EHD USE ONLY OWNER ID# CASE# OWNER FILE COMPLETE THEFOLLOw/NG BUSINESS OWNER INFORMATION.' CHECK IF OWNER CURRENTL v oN FiLE WITH EHD❑ BUSINESS �' � ,p, PHONE: OWNER'S NAME First MI Last BUSINESS NAME(If different from Owner Name) SOC SeC orTax ID# fk� 1" ykpkCA OWNER'S HOME ADDRESS CITY ^1 S ZIP l^r ^6c cc yx _ 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 1 FACILITY ID#: CO-OWNER ID#: ACCOUNT ID#: COMPLETETHEFOLLOw/NG BUSINESS FACILITY INFORMATION.' IS this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO I� s this an EYJSTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ Noy BucwFac/Ge (Tv Neur(This will he the QUS! NESSI Eon�he HEALTH PERMIT) FACT'", A"=CESS(If Fncnmyis a MeeicEF000 UNiror FooO UEHICLEU®e the COMMISSARY ADDRESS) BUSINESS PHONE I�,iGm_`�fD \V CP&li t-G/ W Suite ITY(If FAcrurvisaMO&LEFOOD UN(TOrF000VEH(cLEuse the COMMISSARY CITY) STATE ZI��.�� BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 moi/ MAILING ADDRESS for Health P0fM t(If DIFFEt,ENTfrom FaciiityAddress) AttenU orC are j C1 ` AMV�11 M G AD ESS Cl STA/fa ZIP SIC CODE: APN M. O D— 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 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. CACA APPLICANT'S NAME: C t SIGNATURE: lea Print ` C TITLE: �w�� 0DATE V DRIVER'S LICENSE# PHOTOCOPY REQUIRED) iI 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 Masterfile Record-Green 11/27/07