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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> SHADED SECTIONS FOR EHD USE ONLY OWNER ID# O/S39CJ T ��CASE <br /> OWNER FILE <br /> COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION: CHECK IF OWNER CURRENTLY ON FILE WITH EHD <br /> BUSINESS j� j <br /> C...`�,�'�J l-� // 5 PHONE '_ <br /> OWNER NAME I <br /> First MI Last U �� ?c <br /> BUSINESS NAME(If different from Owner Name) , <br /> _21.-,jax ID# <br /> OWNER HOME ADDRESS <br /> CITY ' <br /> C' C"r, �. �✓ /�t �� STATE ZIP �' �-- <br /> OWNER MAILING ADDR S (If different from Owner Address) Attention or Care of <br /> MAILING ADDRESS CITY <br /> $TATE ZrIP <br /> TYPE OF OWNERSHIP: <br /> CORPORATION❑ INDIVIDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER ETJ <br /> FACILITY FILE <br /> FACILITY ID#: C-D CO-OWNER ID#: ACCOUNT ID#: 33 Z <br /> COMPLETE THE FOLLOWING BUSINESS FACILITYINFORMATION: <br /> IS this a NEW BUSiness LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ NO <br /> BUSINESS/FACILITY NAME(This will be the BusimEss NAmEon the HEALTH PERMIT) <br /> FACILITY ADDRESS(IfF.ACILITYISaMO ILEFoODUNITorFoODVEHICLEusetheCoMMiasn� wAppgrW BUSINESS PHONE <br /> Street Nu Direction SLagi!N suite# <br /> CITY(IfFAaurvls a os FOOD UNITor F000 V imE use the CoMMiceeRv_n ) $TATE zJp <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> MAILING ADDRESS for Health Permit(If DIFFERENT from Facility Address) Attention or Care Of <br /> MAILING ADDRESS CITY ZI <br /> r� STATE P <br /> SIC CODE: APN#: 6��V COMMENT: <br /> LI CCt7IlNT dnnRESS for fees and charges: OWNER ❑ FACILITY/BUSINESS ❑ <br /> Rn I INc AND CQMrI IANCF Ach.Nmyl Foc-ww: I, the undersigned Applicant, certify that I am the Owner, Operator, or Authorized Agent of this <br /> Business,and I acknowledge that all PERMIT FEES,PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation will be <br /> billed to me at the address identified above as the AccuUNTAn RECD for this site. I also certify that all information provided on this application is true <br /> and correct; and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Re ulations. <br /> APPLICANT NAME: SIGNATURE: ` <br /> ­1 Please Print <br /> TITLE: 'i �`. J f^ DATE t/ 9 J;, DRIVER'S LICENSE# <br /> (PHOTOCOPY RFouiREDI <br /> E <br /> proved By Date Accounting Office Processing Completed By Date <br /> D <br /> A PROGRAM(EHD 48-02 34 Pink)or WATER SY TEM(EHD 46-02-003)form must be completed for each EHD regulated operation at this LOCATION except <br /> UST Program(Use SW CB forms) <br /> EHD 48-02-035 <br /> 10/9/2003 <br /> Masterfile Record-Green <br />