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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />SHADED SECTIONS FOR EHD USE ONLY OWNER ID.* I 'rl/K1. ` CASE III <br />OWNER FILE <br />COMPLETE THEFOLLOw/NG BUSINESS OWNER /NFORMAnow CHECK IF OW N E R CURRENTL YON FILE wnH EHD —I <br />OWNERSNAME <br />I YES Er NO ❑ <br />ar � s <br />NO <br />S <br />PHONE: (Xegry <br />7 If I 0 <br />Its, <br />MI <br />Last <br />BUSINESS NAME (If dArereM from Owner Name) ii <br />ved Pi. <br />VN <br />Soc Sec or,:V, # <br />J ,7 C10 <br />CIER'S HOME ADDRESS: C <br />CITY <br />, <br />(If FACIUTYIS a MOBILE FOOD UNIT or FOOD VEHICLE use the Commissmy CITY) <br />/) <br />STATE co <br />ZIP <br />OWNER'S MAILING ADDRESS (If d'Memn(from Owner's Addreea) <br />Il�2o <14ar <br />AttmWn wCue at <br />ccV►KS <br />MAILING ADDRESS CITY ,/t <br />STATE <br />ZIP <br />TYPE OF ONNERBMIP: <br />CORPORATION ❑ INDIVIDUAL ❑ PARTNERSHIP ❑ LOCAL AGENCY ❑ COUNTY AGENCY ❑ STATE AGENCY ❑ FED AGENCY ❑ OTHER ❑ <br />FACILITY FILE <br />FAcILIry ID'#: D6 Z.. 52= 1 CO-OwNFR ID #: - AccouNTID#: j <br />COMPLETE THE FOLLOw/NG BUSINESS FACILITY /NFORMATim- <br />Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? <br />I YES Er NO ❑ <br />Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ <br />NO <br />BUSINEs3/FACIL NAME (This will be the BU&NEssAkmEon the HEALTH PERMIT) <br />I <br />APN: <br />FACIL AODRESS(NFACIu aMOBILEF600 UNIT <br />14 U C I� <br />r FOO�MCLEuse the COMMISSARY ADDRESS <br />D INESS PHONE: <br />Sheet Number Dkr.twa Street Neme Sbee'91 uite <br />C <br />(If FACIUTYIS a MOBILE FOOD UNIT or FOOD VEHICLE use the Commissmy CITY) <br />STATE./nI <br />ZIP /yr 2W <br />BOARD OF SUPERVISOR DISTRICT <br />LOCATION CODE <br />KEY1 <br />KEY21 <br />yry <br />MAILING ADDRESS for Health Perrr)ft(If DIFFERENTfrom Facility Address/ IIF j � S I tkk <br />Atferdlon or Cere Ct <br />) I' {'} <br />1"Ih.Cogl <br />MAILING ADDRESS CITY 90u, <br />ID y) 1Z I <br />STATE / /A <br />liTl <br />zip <br />EMAIL ADDRESS FOR <br />INVOICES <br />INVOICE (1 rri �✓e v$ /�Z /,//,fir/ VOICE <br />EMAIL i tV r✓t MAIL 2 <br />EMAIL ADDRESS FOR <br />OPERATING PEI <br />PERMIT PERMIT <br />EMAIL -1 EMAIL2 <br />ACCOUNTADDRESSforfees and charges: <br />OWNER ❑ <br />FACILITY/BUSINESS ❑ <br />BILLING AND COMPLIANCE ACKNOWLEDGMENT: I, the undersigned Applicant, certify that I am the Owner, Operator, or Authorized Agent of this Business, and <br />I 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 ACCOUNTADDRESS for this site. I also certify that all information provided on this application is true and correct; and that <br />all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or <br />FEDERAL Laws and Regulations. ,( <br />APPLICANT'S NAME: /e41-1�"5 U'��s SIGNATURE: <br />P/ease Print <br />TITLE' DATE�U 9 Z4Z� DRIVER'S LIC <br />ENSE# <br />PHOTOCOPY REQUIRED Al 9�7G goo <br />VVV �y <br />Appr.Yed Sy Dkp et. A000uMOffice Procsssip nCompleted By Deb V//, <br />/ <br />A PROGRAM (EHD 48.02-034 Pink) or WATER SYSTEM (EHD 48-02-003) 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 />9/14/2020 <br />