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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ....ASTERFILE RECORD INFORMATION FCI._. SHADED SEcTro#S/FOR )E��UDD USE ONLY �r OWNER ID# B CASE �4 L✓ ('�1 6 OWNER FILE (`;�'lt h �!F L1�i �: COMPLETE THEFOLLOw/NG BUSINESS OWNER tNFORMAT/ON: CHECK IF OW EHDQ BUSINESST S H Hr OWNER'S NAME J Fast M, Last ZU Ci (}�7 .3L 91/ BUSINESS NAME(if diAeram/rom Owner Name) Soo Sec Or Tex ID# —7--77 / Tl Na Io '� tvybv0rrvE -j / ' S 7Uf OWNER'S HOME ADDRESS CITY tJ (A STATE LP OWNER'S MAILING ADDRESS (If dMerentfi smOwner's Addrese) Attention orCare of TRA"I ti`rM/{ NN MAILING ADDRESS CITY ;n ^ C SLATE ZIP 'IS 3.7 R4j TYPE OF OWNERSHIP: CORPORATIO INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY DTXER❑ FACILITY FILE FACILITY ID#: CO-OWNER ID#: 7 ACCOUNT ID#:' COMPLETE THEFOLLOw/NG BUSI NESS FACILITY/NFORMA now Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES NO ❑ na .e.....,» Is this an ExISTING Business LOCATION but a NEIN TYPE of regulated Business? YES ❑ No E3' BUSINESS/FACILITY NAME(This will be the Bus/NEss AAwEon the HEALTH PERMIT) FACILITY ADDRESS(If FAa[nris a MOSZUFF0 Uwror F000 VEHImEuse the COMMISSARY ADDRESS) BUSINESSPHONE � eci,le S- ['o/t/tq � HOLcr.✓ " ;Z14 ,-I Suite# ' JV qqaY> CITY(If FAGurea a MOaRE FOOD UNIT Or FOOD VENIcLEuse the COMMISSARY CnrI .STATE Zip c`I /) G" ��S j'77 BOARD OF SUPERVISOR DISTRICT LOCATION CODE �-//2 KEYI KEV2 MAILING ADDRESS for Health Permit(if DIFFEREHTfrom Fe XtyAddress) Attention orCsre Of c A a Sufi MAILING ADDRESS CITY STATE ZIP i IAL C 9s3 � 5' SIC CODE: APN#: Z 5 3 t O COMMENT: ACCOUNTADDRE$F for fees and charges: OWNER ❑ 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 to 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 JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or FEDERAL Laws and Regulations. APPLICANT'S NAME:^_ .S N �"� PI N D �/c l' L _S /A-61I'I SIGNATURE: Please Print < //' TITLE: y. N p l' y r` DATE I� l 3 PHOTOCOPY REQUIRED)RIVER'S LICENSE# �J ��" Approved U '`U Date (0 [ I I A—Ming!Office Processm Processing Completed By DNe A PRGGRAW JEHD 48-02-034 Pink)or `WATER SYSTEMI(EHD 464II241101,ificim tm be Completed for each EHD regulated open ttia(n at this L CAAT11 except UST Program(Use SWRCB forms) EHD 48-02-035 Masterfile Record-Green 8119/08