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SAN JOA.. _.N COUNTY ENVIRONMENTAL HEALTH DL .RTMENT MASTERFILE RECORD INFORMATION FORM SHADED SECTIONS FOR EHD USE ONLY OWNERID# CASE# OWNER FILE �iJy-SRm(�yCr53 COMPLETE THEFOLLOwwa BUSINESS OWNER tNFORMATtON. CHECK/F OWNER CURRENTLYONFILEw?HEHD❑ BUSINESS PHONE: OWNER'S NAME 70 First MI Lest —4 BUSINESS NAME(If different,from Owner Name) SOSec orTax ID# 5,4„6WIIA,,%e iV OWNER'S HOME ADDRESS IM CITY QST 146LAA& FEW I ZIP 9 ys7 OWNER'S MAIUNO ADDRESS(Hdifferantiivn Cwner'e Addn&M,) Attention orCare of d?o, x ERIC- MAILING ADDRESS CITYT •\ TATE Zlp Orf I S TYPEOFOWNERSHIP: V V _(T CORPORATION X INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY COUNTY AGENCY El STATE AGENCY FED AGENCY❑ OTHER❑ FACILITY FILE -II FACT T ID#: CO-OWNER 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 EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No BUSINESS/FACILITY NAME Thiswillbe the Bus NEssNAuEon the HEALTHPERMIT) ^ L AJo- e P /L T FACILITY ADDRESS(if FAcxmis a MOacEFOODUMTor Foo E=Euse the CommissARYAODRESS) BUSINESS PHONE / 5667 N. T'YV-40 3 644(.c 2D 0 _ Suite# 7 CITY(If FAclury is a MOBILE FOOD Umrror Food VIEwcl.E use the CoMmissNtY Cm) $TATE zip C S BOARD OF SUPERVISOR DISTRICT LOCATONCODE KEY1 KEY2 MAILING ADDRESS for Health PWM1t(If D/FFERENTfrom FacilityAddress) Attention orCare Of Ms S L T SIG tiSS� MAILING ADDRESS CITY STATE zip SIC CODE: APN II—D9(�;L 03 COMmENr:645-5-r O ,f6 /O _IVITBQ/A1G 11.5 /4CCOUlNTf100k for fees and charges: OWNER ❑ FACILITY/BUSINESS BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner,Operator,or Author/Zed 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 Regulations. AL APPLICANT'S NAME: F&L L )4A Ati NATURE: P ease Print TITLE: VER'S LICENSE#DATES 2� L PHIOTOCOPY REQUIRED O Approved By Date Accounting Office Processing Completed By Det_ A PROGRAM{EHD 48-02-034 Pink)or WATER SYSTEM(EHD 48-02-003)formIn ust be completed for each EHD regulated operation at this LOCATION except UST Program(Use SWRCB forms) EHO 48-02-035 Masterfile Record-Green 11127/07