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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM SHADED SECIIONS FDREHD USE ONLY OWNERID# CASE# OWNER FILE COMPLETE THE FOLLOWINGBUSINESS OWNER INFORMATION; CHEcKrF OWNER CURRENTLYON FILE WrTNEHD❑ BUSINESS h O 2 D• L� PHONE: OWNER'S NAME L �-f� �� Firs( MI BUSINESS NAME(If dillarentfmm Owner Name) SOC Sec OrTax ID It E( lz-'+ UrJb S3- a er -4£oq 4 OWNER'S HOME ADDRESS CITY 5 ?� K� � STATE ZIP 744-0-3 OWNER'S MAILING ADDRESS (If di0erent rmm owner's Address) Attention or Care of b- 60 � z3 MAILING ADDRESS CITY C STATE ZIP 4/A/I O `2 yd F l2Lco L T'C 3 TYPE OF OWNERSHIP: CORPORATION❑ INDMDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER FACILITY FILE ef(U24 �o2j� CLclfp FACILITY ID#: CO.OWNER 10#: AccouNTID#: COMPLETE THE FOLLOWING BUSINESS FACILITY INFORMATION; Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES No ruL- Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No 7N BUSINESS/FACILITY NAME(This will be the SumNrssNaveon the HEALTH PERMIT) - E,L Lnc� o?-+ b FACILITY ADDRESS(If FArzurris a Mogi„Fox Uwror FIX»Ven use the CommisSEYADonrss) BUSINESS PHONE �•�' 92�Js� Llt�) �BlE_$beb et Number DircxYron Sbeer Name fT a suite CITY(if FAaLnY15 a MDBILEFOOD UNfror FOOD VEHICLE use the CoiNessA CITY l STATE f-4 z-ko CA- ZIP 2 BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEYI KEY2 - MAILING AI)DREss for Heath PBrmit(If DIF)FRENTfrom Fad/ityAddr ) Attention orCare Of 4. A L(F— MAILING ADDRESS CITY STATE ZIP SIC CODE:. APN#: COMMENT; -. ACC01ff-” VRE$'.5-fOr fees and charges: OWNER ❑ FACILITY/BUSINESS BILLING AND COMPLIANCE ACKNOWLEDGMENT: [,the undersigned Applicant,certify that 1 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 ccordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or FEDERAL Laws and Regulations. C>+-4-2. u Y APPLICANT'S NAME: ' SIGNATURE: Please Pn' TITLE: If L- T+ I t-A-6 LI pF� DATE J, ( DRIVER'S LICENSE# y.� `1Y ^ 6-Ed 5 t/� _ 'L ✓ - ` PHOTOCOPY RE UIRED eO APPrtiv,d fly z� Date �An unting Office Processing Completed Uy I --�: A PROGRAM (END 46-02-034 Pink? or WATER SYSTEM (END 46-02-003) form must be completed for each EHD regulated o s TI N except UST Program(Use SWRCB fortes) P reg Aeration at this EHD 48-02-035 8/19/08 Mastetfle Record been