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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM SH EO SECTms FOR EHD USE Ow Y OWNER ID# 017It-7S3 CASE# OWNER FILE COMPLETE THEFOLLOWTNGSUSI NESS OWNER INFORMATION.' CYreCKAF OWNER CURRENaYONRLE WMEHD❑ BUSINESS PHONE: OWNER'S NAME 9/ MI Last & -3 7i-Ylk o First BUSINESS NAME(8 dReranflromOwrrerNMrfe) Soc Sec orTax ID# LA Tic VICE 9 - 3ga�la OWNER'S HOME ADDRESS a CITY l.1 e L O I SM 7j° S 9 OWNER'S MASJNG ADDRESS(If d#Yerent From Owner's Address) AMention orCare of Pb PQM a MAILING ADDRESS CITU I^' e C 1 /a�N L $T TE LP q�"b Q Tree OF OWNERSHIP: YV JT 1 '\CJ J )=j CORPORATION INDIVIDUAL❑ PARTNERSHIP L1 LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY El OTHER El FACILITY FILE FACIUTY ID#: C Q Z y�SJ CO-OWNER ID#: ACCOUNT ID#: O r('j7 COMPLETE THEFOLLOW/NG BUSINESS FACIUTY INFORMA now r,/ Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES [7 NO ❑ Is this an EIS TING Business LOCATION but a NEw TYPE of regulated Business? YES ❑ No ❑ BUSINESSIFACILITY NAME(This will be fhe Bu,%Nism NulEon the HEALTH PERAIM I--AAAA -I &P71c Ste- ✓IcE c . FACILITY ADDRESS(if FA is a Nb Feou UNrror F000✓iwxc use the COMMISSARY AooRessl BUSINESS PHONE 733Y West YV4 S!- 3u a# 9/G -37/-y a /G CITY(if FAou rs a Mosa-=Fern UNTor Food Vasr.vuss the CoNre lyvxr Cl Tvl STATE LP 9t Q C N0A C4- 9Sto 73 BOARD OF SUPERVISOR DISntlO LccAnoN CODE KEY1 KEY2 MAILING ss A7FHeaM Perm ffiff DYFFEREArr"m Fac!/iyAddrassi AtteMlon arCar s Of MAILING ADDRESS CITY iye y SG C r4mcf1yo $T LP 9569/ SIC Cool APN t tipaFHT: ACCDOIllfrAILIVREW for fees and Chargee: OWNER ❑ FACILITY/BUSINESS 1-1 BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that 1 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 t0 me at the address identified above as the ACCOUNT ADDRESS 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 we and Regulations. C Fl APPLCANT'SNAME: ;q —I SE7/C ��✓(CEh/✓C SIGNATURE: Alli ,, L Please Print — /�� TITLE: /W` — 01--n-1 DATE `2�' PHOTO COPYREDUIRED /I &IS& ��LO Approved By Date Accounting Office Processing Completed By -24L I Daft A PROGRAM(EHO 48-02-034 Pink)OF WATER SYSTEM(EHD 43-02-003)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