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SHADED $ECTIONS FOR EHD (ISE ONLY <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />OWNER ID # CASE # <br />OWNER FILE <br />COMPLETETHEFOLLOW/NGBUSTNESS OWNER INFORMATION.' <br />CHECK IF OWNER CURRENTLYONFILEw/THEHD" <br />TYPE OF OWNERSHIP; <br />CORPORATION INDIVIDUAL ❑ PARTNERSHIP ❑ LOCAL AGENCY ❑ COUNTY AGENCY ❑ STATE AGENCY ❑ FED AGENCY ❑ OTHER ❑ <br />FACILITY FILE <br />FACILITY ID <br />IS this a NEW BUSIneSS LOCATION Or VEHICLE not <br />#: <br />CO-OWNER <br />ID <br />#: <br />ACCOUNT ID #: <br />COMPLETETHEFOLLOW/NG <br />BUSINESSa <br />OWNER'S NAME <br />t <br />� ' 1 l� <br />INFORMATION: <br />�r'� <br />1 <br />PHONE: <br />`y (� <br />( <br />I <br />1 (� D l <br />t b <br />First <br />MI <br />Last <br />BUSINESS NAME (If different from Owner Name) <br />sJ 1A Yy F�Dl CAL <br />f59 A 1 fWTt <br />Soc Sec orTax <br /> <br /> <br /> <br />OWNER'S HOME ADDRESS 1 <br />1 <br />ST� <br />CITY <br />ZIP <br />S E <br />ZIP <br />�% S7 <br />C� <br />OWNER'S MAILING ADDRESS (If diflerentfrom Owner's Address) <br />KEY1 <br />Attention orCare <br />of <br />KEY2 <br />MAILING ADDRESS CITY <br />MAILING ADDRESS for Health Perm/t(If DIFFERENTfrom Facility Address) <br />STATE <br />ZIP <br />MAILING ADDRESS CITY <br />STATE <br />ZIP <br />TYPE OF OWNERSHIP; <br />CORPORATION INDIVIDUAL ❑ PARTNERSHIP ❑ LOCAL AGENCY ❑ COUNTY AGENCY ❑ STATE AGENCY ❑ FED AGENCY ❑ OTHER ❑ <br />FACILITY FILE <br />FACILITY ID <br />IS this a NEW BUSIneSS LOCATION Or VEHICLE not <br />#: <br />CO-OWNER <br />ID <br />#: <br />ACCOUNT ID #: <br />COMPLETETHEFOLLOW/NG <br />YES ❑ <br />BUSINESS FACILITY <br />INFORMATION: <br />ACCOUNTADORESS for fees and charges: OWNER ❑ FACILITY/BUSINESS <br />Is this an EXISTING Business LOCATION but a <br />preVIOUSIy regulated by the ENVIRONMENTAL <br />NEW TYPE Of regulated Business? YES <br />HEALTH DEPARTMENT? <br />❑ No ❑ <br />YES ❑ <br />NO ❑ <br />BUSINESS/FACILITYNAME (This will be the SUS4VESSNAm4on the HE(A''LfL�H PEER,MIIT) <br />FACILITY ADDRESS (If FAcatryis a MOBILEFOOD <br />!c `M � <br />UNITOr FoOD VEHICLEuse the COMMISSARY ADDRESS) <br />� C <br />Suite <br />BUSINESS PHONE <br />71Lre15w4r=2fl`©1 <br />CITY (if FaaurrlsaMOBILE FOODUNIT Of' FOOD VEH/CLEDSetIIeCOMMISSARYCnY) <br />`' Ic i J1 <br />ST� <br />ZIP <br />J� <br />LJ <br />BOARD OF SUPERVISOR DISTRICT <br />LOCATION CODE <br />KEY1 <br />KEY2 <br />MAILING ADDRESS for Health Perm/t(If DIFFERENTfrom Facility Address) <br />Attention orCare Of <br />MAILING ADDRESS CITY <br />STATE <br />ZIP <br />SIC CODE; <br />APN #: <br />COMMENT: <br />❑ <br />BILLING AND COMPLIANCE ACKNOWLEDGMENT: I, the undersigned Applicant, certify that I am the Owner, Operator, or Authorized Agent of this Business, and I <br />acknowledge that all PERMIT FEES, PENALTIES, ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with <br />this Operation WIII be billed to me at the <br />address identified above as the AccouNTADOREss for this site. I also certify that all information provided on this application is true and correct; and that all <br />regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or FEDERAL <br />Approved By Date Accounting Office Processing Completed By Date <br />A PROGRAM {EHD 48-02-034 Pink} or WATER SYSTEM {EHD 46-02-003} form must be completed for each EHD regulated operation at this LOCATION <br />except UST Program (Use SWRCB forms) <br />EHD 48-02-035 Masterfile Record -Green <br />11127/07 <br />