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SAN JOAN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM SHADED SECTIONS FOR EHD USE ONLY OWNER ID# CASE# OWNER FILE COMPLETE THEFOLLOW/NG BUSINESS OWNER/NFORMAT/ON.' CHECK IF OWNER CuRRENrL r ON FILE WITH EH0 BUSINESS k— PHONE: OWNER'S NAME First MI Last BUSINESS NAME(If di9erentfrom Owner Name) Soo Sec orTax ID# OWNER'S HOME ADDRESS 21k�o yt . Clry-TV( A S 2 OWNERS MAILNG 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#: COMPLETE THEFOLLOW/NG BUSINESS FACILITY/NFORMAT/ON.' Is this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO ❑ Is this an EwSTING Business LOCATION but a NEw TYPE of regulated Business? YES ❑ No ❑ B ESS/FACI NAME(TN will be the But;Vz AAMEon th EALTH PERMIT) FACILITY ADDRESS(11 PA,.-----u....,.-FooDUNNIror FOOD C[Ee6e Ne COMMISSARYADDRESS) �Q� 2 �- L4P,f BUSINESS PHONE Suite# CITY If FALuI is a MOBILE FWD UNDOr FOOD VEHICLE use the COMMISsA Owl STATE ZIP BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 MAIUNG ADDRESS TK no PennK(If DIFFERENT rom FacilityAddress) Atte Ion orCare Of I"c illi ADDRE S CITY ST{�FZIP(K-� SIC CODE: APN#: COMMENT: -` ACCOUNT ADDVUS 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. 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 and/or FEDERAL Laws and Requisitions. APPLICANT'S NAME: Ca SIGNATURE: P/ ePri I TITLE: DATE 6 L DRIVER'SLICENSE# PHOTOCOPY REQUIRED Approved By Date Accounting Office Processing Completed By Date A PROGRAM(EHD 48-02.034 Pink)or WATER SYSTEM{EHD 48-02.003)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