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SHADED SECTIONS FOR EHD USE ONLY SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM OWNER ID # CASE # OWNER FILE COMPLETE THE FOLLOW/NG BUST N ESS O W N E R INFORMAT/ON.' CHECK IF OWNER CURRENTLYONFILEwtTHEHDI 1 TYPE OF OWNERSHIP: CORPORATION INDIVIDUAL ❑ PARTNERSHIP ❑ LOCAL AGENCY ❑ COUNTY AGENCY ❑ STATE AGENCY ❑ FED AGENCY ❑ OTHER ❑ FACILITY FILE FACILITY ID #: CO-OWNER ID #: ACCOUNT ID #: COMPLETETHEFOLLOW/NG BUSINESS FACILITY INFORMATI ON: IS this a NEW Business ACCOUNTADORESS for fees and charges: OWNER FA LOCATION Or VEHICLE not preVIOUSIy regulated by the ENVIRONMENTAL Is this an ExISTING Business LOCATION but a NEw TYPE of regulated Business? YES HEALTH DEPARTMENT? YES NO ❑ ❑ No BUSINESS OWNER'S NAME BUSINESS/FACILITY NAME (This wil be the BUSINESSNAMEOn the HEALTH PERMIT) H F LSC PHONE: First MI FACILITY ADDRESS (If FACILITYIs a MOBILEFOOD UNITor FOOD VEHICLEUse the COMMISSARY ADDRESS) Last BUSINESS NAME (If different from :S �✓- Owner Name) F L L_ L CITY (If FACILITYIs a MOBILE FOOD UNIT or F000 VEHicLE use the COMMISSARY CITY) C_ cwt Soo Sec orTax ID # OWNER'S HOME ADDRESS �s7J oU L04z it'r �;^, CITY k010 x pr, ll zS LOCATION CODE KEY1 ZIP 3 7 9C' Cr OWNER'S MAILING ADDRESS (If different from Owner's Address) MAILING ADDRESS for Health Permit(If D/FFERENTfrom FacilityAddress) Attention or/Care of DC4,S T#:L l3 LtVa4 MAILING ADDRESS CITY STATE zip STATE -%t ' /V zip .7 .7 2 ✓ / 0 SIC CODE: APN #: TYPE OF OWNERSHIP: CORPORATION INDIVIDUAL ❑ PARTNERSHIP ❑ LOCAL AGENCY ❑ COUNTY AGENCY ❑ STATE AGENCY ❑ FED AGENCY ❑ OTHER ❑ FACILITY FILE FACILITY ID #: CO-OWNER ID #: ACCOUNT ID #: COMPLETETHEFOLLOW/NG BUSINESS FACILITY INFORMATI ON: IS this a NEW Business ACCOUNTADORESS for fees and charges: OWNER FA LOCATION Or VEHICLE not preVIOUSIy regulated by the ENVIRONMENTAL Is this an ExISTING Business LOCATION but a NEw TYPE of regulated Business? YES HEALTH DEPARTMENT? YES NO ❑ ❑ No BUSINESS/FACILITY NAME (This wil be the BUSINESSNAMEOn the HEALTH PERMIT) H F LSC FACILITY ADDRESS (If FACILITYIs a MOBILEFOOD UNITor FOOD VEHICLEUse the COMMISSARY ADDRESS) Suite # BUSINESS PHONE CITY (If FACILITYIs a MOBILE FOOD UNIT or F000 VEHicLE use the COMMISSARY CITY) C_ cwt STATE C ' A zip 9 BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 MAILING ADDRESS for Health Permit(If D/FFERENTfrom FacilityAddress) Attention or/Care Of MAILING ADDRESS CITY k STATE -%t ' /V zip .7 .7 2 ✓ / 0 SIC CODE: APN #: COMMENT: FACILITY/BUSINESS ❑ BILLING AND COMPLIANCE ACKNOWLEDGMENT: [,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 aSSOClBted with this operation WIII be billed t0 me at the address identified above as the AccoulvTADOREss 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: JJ LLS / /S %%� '� SIGNATURE: Please Print TITLE: DATE//t�/Z DRIVE R'SLICENSE# 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 except UST Program (Use SWRCB forms) EHD 48-02-035 Masterfile Record -Green 11/27/07