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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> SHADED SECTIONS FOR EHD USE ONLY OWNER ID# /g, J ELI74 <br /> 74u CASE# <br /> vO"WNER FILE <br /> COMPLETE THE FOLLOWINGBUSINESS OWNER INFORMA ITON., CREcKrE OWNER CURRENTLY ON FrLE wrTN EHD❑ <br /> BUSINESS PHONE: <br /> OWNER'S NAME w <br /> Fk# MI Last <br /> BUSINESSS NAME(If d#&YWt ftM Owner Name) Sac Sec OrTax ID# <br /> /v <br /> OWNER'S HOME ADDRESS n .+ Sa <br /> CITY O 'fl STATE zip <br /> OWNS ' MAILING ADDRESS (If dhr&MtfMM Owner's Address) Attention OrCare of <br /> MAILING ADDRESS CITY / O /-T. �. l\, STATE ZIP <br /> TYPE OF OWNERSHIP: <br /> NJQ <br /> INDMDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITYID#: DO2(13 CO-OwNERID#: ACCOUNT ID#: A 4-D3�t� <br /> COMPLETE THE FOLLOWING BUSINESS FACILITY INFORMATION: <br /> Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES NO <br /> Is this an ElaSTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No (� <br /> BUSINESs/FAQLrrY NAM'fjE(This will be the BuaR NANEon the HEALTH PERMIT) <br /> -. <br /> FACILITY ADDRESS(If FAe isaMCMEFbCdUwTorfOmuw4heCOMMIBUSINESS PHONE <br /> N Nme 5"et TJ406 Suite2932 <br /> CITY(If FAa ft a MOBILEFDODUMTOr FOOD VENMlEUSe the COMMSSARY Cm) STATE zip <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEYI KEY2 <br /> MAI LING ADDRESS for Health Permlt(If DIFFERENTfro,Faci/ilyAdd,,$) Attention OrWre Of <br /> MAILING ADDRESS CITY STATE zip <br /> SIC CODE: APN#: ConneNr: <br /> ACCOUNT_ ADDRESS for fees and charges: OWNER1,2 FACILITY/BUSINESS ❑ <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and <br /> acknowledge that all PERMIT FEES,PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this Operation will be billed to me at the <br /> address identified above as the ACCOUNT ADDRESS for this site. I also certify that all information provided On th' application is true and correct;and that <br /> all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance des an Standards and STATE and/Or <br /> FEDERAL Laws and Regulations. <br /> APPLICANT'S NAME: ')v)2= (��/{ a )/ / <br /> SIGNATURE' <br /> Please Pdnt <br /> TITLE: DATE y DRIVER'S LICE # /v e�� '3'� '7 <br /> PHOTOCOPY UIRED <br /> Approved By Date 1 -12 -12 <br /> „/Z / Accounting Office Processing Completed <br /> -02-003} form must be completed for each GEHD-regulated operation at this <br /> A PROGRAM {EHD 48-02-034 Pink} or WATER SYSTEM {EHD 46 <br /> LOCATION except USF Program(Use SWRCB forms) <br /> EHD 48-02-035 <br /> 8/19/08 Masterfile Record-Green <br />