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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM SHADED SECTIONS FOR EHD USE ONLY OWNER ID# CASE# OWNER FILE COMPLETE THE FOLLOw/NGBUSINESS OWNER INFORMATION.' CHECKIF OWNER CURRENTLYONF/LEw/THEHD❑ BUSINESS Pa Lk t �r'� PHONE: , OWNER'S NAME ' 1 l� 1 `y ( � Ell (� D I First MI Last ( t b l BUSINESS NAME (If different from Owner Name) Soc Sec orTax ID# sJ A OWNER'S HOME ADDRESS 1 1 CITY Z S OWNER'S MAILING ADDRESS (If different from Owner's Address) Attention orCare of MAILING ADDRESS CITY STATE ZIP TYPE OF OWNERSHIP: CORPORATIONe INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER ❑ FACILITY FILE FACILITY ID#: CO-OWNER ID#: ACCOUNT ID#: COMPLETETHEFOLLOW/NG BUSINESS FACILITY INFORMATION: Is this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO ❑ IS this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ NO ❑ BUSINESS/FACILITY NAME (This will be the Bus ESSNAM on the HEALTH PERMIT) FACILITY ADDRESS(If FAcatrvis a MOBILEFOOD UNITOr FoOD VEHICLEuse the COMMISSARY ADDRESS) BUSINESS PHONE !c) ` q Ckt_L_0Wr_V3 Strp Street Type Suite# C-✓ 4e='�'R©f CITY(if FAaurrlsaMoe/LEFOODUN/TOf,FOOD VEHICLE use tIIeCOMMISSARYCITY) .ST� ZIP !`lllllc¢�fiTVi J, BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 MAILING ADDRESS for Health Perm%t(If DIFFERENTfrom Facility Address) Attention orCare Of MAILING ADDRESS CITY STATE ZIP SIC CODE; APN#: COMMENT: ACCOUNTADORESS for fees and charges: OWNER ❑ FACILITY/BUSINESS ❑ BILLING AND COMPLIANCE ACKNOWLEDGMENT: I, the undersigned Applicant, certify that I 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 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. APPLICANT'S NAME: �� ' / 1 ' �1 �-'� '`� SIGNATURE: Pleas Pi TITLE: . I n DATE 2r^ 2 I DRIVER'S LICENSE# W PHOTOCOPY REQUIRED Approved By Date Accounting Office Processing Completed By Date 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 J except UST Program (Use SWRCB forms) EHD 48-02-035 Masterfile Record -Green 11/27/07