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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT , ,STERFILE RECORD INFORMATION FOI, SHADED SECTIONS FOR EHD USE ONLY OWNER ID At CASE At OWNER FILE COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION: CHEcKrF OWNER CURREN77Y ON FILE WITH EH D BUSINESS PHONE: OWNER'S NAME Fbst MI Last BUSINESS NAME(If different from Owner Name) SOC Sec Or Tax ID# P, wlo,Tf SerUiU_i co OWNER'S HOME ADDRESS CITY STATE ZIP OWNER'S MAILING ADDRESS (If different from Owners Address) Attention or Care of MAILING ADDRESS CITY STATE ZIP TYPE OF OWNERSHIP: CORPORATION❑ INDMDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHE0.❑ FACILITY FILE FACILITY ID#: �-�a,I - CO-OWNER D#: ACCOUNT ID/F: COMPLETE THE FOLLOWING BUSIN ESS FACILITY INFORMATION: �rT 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( s will be the SOSINEssNaureon the HEALTH PE IT) CPL- I f-orZw1 A ;74q �, 79avK, E FACILITY ADDRESS(If FAa[mis a Mtei�Fcoo UNtror FOOD✓VuIGZ a the COMMI554RY AODPEss) BUSINESS PHONE I " I S CA2DIMori, Qur 51 Number Dreccon Sfreef Name StreetT Suite ft -I�_ -" CITY(If FACILITY IS a Mi FOOD UNIT or FOOD VEHICLE Use the COMMISSARY CIT') STATE ZIP �� ST L,ILToa � I BOARD OF SUPERVISOR DISTRICT pb LOCATION CODE O I I4EYII KEY2 MAILING ADDRESS for Health PerDHt(lf DIFFERENTfrom Fachty Address) Attention or Care Of MAILING ADDRESS CITY STATE ZIP SIC CODE: APN#: COMMENT: ACCOUNTADDRESS for fees and charges: OWNER Q 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 t0 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 JOAGUIN COUNTY Ordinance Codes and/or Standards and STATE and/or FEDERAL Laws and Regulations. APPLICANT'S NAME: SIGNATURE: Please Pnnt TITLE: DATE DRIVERS LICENSE# �t Approved BY r1/�.J PHOTOCOPY REQUIRED) counting Ofice Processing Completed BY 1)12 Date --D." B Z,j A PROGRAM (EHD 48-02-034 Pink) or WATER SYSTEM {EHD 46-02-0031 form must be completed for each EHD regulated operation at this LOCATION except UST Program (Use SWRCB forms) EHD 48-02-075 Masterfile Record-Green 8/19 08