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SAN JOAN COUNTY ENVIRONMENTAL HEALTH DATMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> SHADED SECTIONS FoREHD USE ONLY OWNER ID III CASE III <br /> OWNER FILE <br /> COMPLETE THEFOLLOW/NG BUSINESS OWNER INFORMATION.' CHECK IF OWNER CURRENTL YONFILE WrHEHD❑ <br /> BUSINESSPHONE: <br /> 0.-,, <br /> OWNER'S NAME <br /> First I MI Last <br /> BUSINESS NAME(If different from Owner Name) SOC Sec orTax ID# <br /> 10 i <br /> OWN ER'S HOME ADDRESS el r 6n, &�_ On <br /> CITY STATE Zip <br /> ��a C o c? <br /> OWNER'S MAILING ADDRESS(If different from Owner's Address) Attention arCare of <br /> MAILING ADDRESS CITY STATE zip <br /> TYPEOFOWNE"HIP: <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP El LOCALAGENCY❑ COUNTYAGENCY❑ STATE AGENCY❑ FEDAGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID#: CO-OWNER ID#: ACCOUNT ID#: <br /> COMPLETETHEFOLLOW/NG BUSINESS FACILITY INFORMATION.' <br /> Is this a NEW Business LOCATION Or VEHICLE not preVioueiy regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES El No <br /> Is this an EXISTING Business LOCATION but NEW TYPE of regulated Business? YES El No Z <br /> BUSINESS/FACu. NAME is y�Jl be the mNEEBAGMEo the HEALTH PERM <br /> wr 1.e/( r�C� �/ e �:a.e4 Oil P/ . <br /> FACILITY DRESS gfFAaLmb a MoeaEF000 UNnor FOOD VEmcteuae the COMMISSARY ADORES sl BUSINESS PHONE <br /> /�U Suite# <br /> CITY(if FACIurYIs a MOEILEFODO UNIT or FOOD,VEHICLE use the COMMIssARY Owl STATE zip <br /> � rFc GA <br /> BOARD OF SUPERVISOR DISTRICT LOCATON CODE KEYI KEY2 <br /> MAILING ADDRESS for HeRIM Permit(If OIFFERENTfrom FaeilityAddress) AtteanorCei Of onra a- e3 <br /> MAILING ADDRESS CITY STATE zip <br /> SIC CODE: APN#: CCMMENT: <br /> ACCOUNTAOORESSfor 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 WIII 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. ,y / <br /> APPLICANT'S NAME: CO G/ SIGNATURE' <br /> / / Please Print <br /> TITLE: / IC EN SE <br /> ed Go F DATE S��L3��Y PHOTOR <br /> O'COPY REQUIRED <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 forme) <br /> EHD 45-02-035 Masterfile Record-Green <br /> 11/27/07 <br />