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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM SHADED SEcimsFOREHOUSE ONLY OWNER ID# CASE# OWNER FILE COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION. CHECK it OWNER CURREimYON FILE wirm EHO F BUSINESSL4. 1JRZ_ PHONE: OWNER'S NAME First All Lest Z Z BUSINESS NAME(If different from Owner Name) Soo Sec orTax 10# J -75' 2,6 07- OWNER'S rOWNER'S HOME ADDRESS CITY S ZI� OWNER'S MAILING ADDRESS (If different from Owner's Address) Attention orCare of MAILING ADDRESS CITY STATE ZIP TYPE OF OWNERSHIP: CORPORATION❑ INDIVIDUAL W PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY OTHER 0 FACILITY FILE FACILITY ID#. CO-OWNER ID#: ACCOUNT ID#: COMPLETE THE FOLLOWING BUSINESS FACILITY/NFORMATIONl Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES ❑ NO ❑ flcoe eru 0 Is this an ExiSTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ NO ❑ BUSINESS/FACILITY NAME(This will be the Duswess NAmEon the HEALTH PERMIT) 'f S FACILITY ADDRESS(If FAclt miss a MovILEF000 UNITor F000 VEHImEUse the COMMISSARYAooRESSJ BUSINESS PHONE 21• S . S P"C A ASC—Nmo ST: Suite# Z c>f.Z f,D 3- 2 I' CITY(If FAciL r is a MoaiLE FooD UNlror F000 VEHICLE use the CoMMlsSARY CITY) STATE ZIP L ct� S S" BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY 1 KEY2 MAILING ADDRESS for Health Perm/t(If DIFFERENTfrom Facility Address) Attention orCare Of MAILING ADDRESS CITY STATE ZIP SIC CODE: APN#: COMMENT: ACCOUNTADDf$S for fees and charges: OWNER ❑ FACILITY/BUSINESS Jey BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERMIT FEES,PENALrws,ENFORCEMENT CHARGES and/Or HOURLY CHARGES associated with this operation will be billed t0 me at the 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 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: A 1 SIGNATURE: Please Print DRIVER'S LICENSE# TITLE: DATE PHOTOCOPY REQUIRED) DS Approved By Date Accounting Office Provessing Completed By Date A PROGRAM(END 48-02-034 Pink)or WATER SYSTEni(END 46-02-003)form must be completed for each END regulated operation at this LOCATION except UST Program(Use SWRCB forms) MaslarFila Record-Green EHD 48-02035 8119/08