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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM SHADED SECTIONS FOR EHD USE ONLY OWNERID# bWXxq-�3 CASE OWNER FILE COMPLETE THEFOLLOW/NG BUSINESS OW N ER/NFORMA now: CHECK IF OWN ER CURREA07L Y ON FILE KnTHEHDEI BUSINESS Hapj /��, C'i PHONE: /N"I OWNER'S NAME l/ J First Ml Last BUSINESS NAME(Il diAerentfromOv, rName) 'SOCSe 'rTax lD# OWNER'S HOME ADDRESS 3 211ro AvV, CITY S f STA ZIP OWNER'SMAI N DD SS(if different from Owner's Address) Attention orCare of [MAILING ADDRESS CITY `/in n $T TE ZIP ^ /� f TYGEOF�HERS IP: f a CORPORATION❑ INDIVIDUAL PARTNERSHIP❑ LOCAL AGENCY[I COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ FACILITY FILE FAciurY ID#: rA 002,5' 2� 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 ExISnNc Business LOCATION but a NEW TYPE of regulated Business? YES C3No 62EN BUSINESS/FACILITY NAME(This will bethe Bus/NEssNA.MEon the HEALTH PERMIT) J�Ss I C't c4r�l�AfM FACILITY ADDRESS(If FAaurYls a Moaf EFWD Uwror FOOD VEHccEUS0 the COMMISSARY ADDRESS) (/V r BU,SINESS PHONE 3412- E M�ncr Amit (2oq) qf8'- pa4 Suite# CITY FAGUIYIsa MD&LEFODD UNRor FDDD Wmcu me the COMMIsswr Cm, STATE ZIP C Qq 9Gj�20 BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 MAILING ADORESSIOr Health Perm If OIFFERENTfrom Fac,114Addrnss) Attention orCare Of r M tzG - Sin h MAILING ADDRESS CITY STATECrfo ZIP J� SIC CODE: JTL/L� APN 0: COMMENT: I A_CCSl1/1YJAPpJ3ESS for fees and charges: Ow R J2FACILITY/BUSINESS ❑ BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner,Operator,Or Authorized Agent of this Business,and 1 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. `P APPLICANT'S NAME: SIGNATURE: V Please PrintJ jT17L , D (,�?7ey DATEJ(�/LSI 2 [� DRIVER E 'S LICENSE III q /- - PHOTOCOPY REQUIRED 2 6 6 Approved ByLODate / _/24 2,1n„ Accounting Office Processing Completed By75 1 Date WO I �D A PROGRAM(EHD 48-02-034 Pink)or WATER SYSTEM(EHD 46-02-003)form must be completed for each EHO regulated operation at this LOCATION, except UST Program(Use SW RCB forms) EHD 48-02-035 Masterfile Record-Green 11/27/07