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SAN JOAO'IIN COUNTY ENVIRONMENTAL HEALTH DFDARTMENT <br /> ,iSTERFILE RECORD INFORMATION FOI <br /> SHADED SECTIONS FOR EHD USE ONLY OWNER ID# a CASE# <br /> OWNER FILE <br /> COMPLETE THEFOLLowNG BUSINESS OWNER INFORMATION. CHECK IF OWNER CuRRENTLYoNFiLE NnTHEHD <br /> BUSINESS �_ PHONE: <br /> OWNER'S NAME S&njin(Al: 444 <br /> Fist MI Last <br /> B SINESS NAME(If dlRetent/mm Owner Name) SOC SBC orTax ID# <br /> OWNER'S HOME ADDRESS <br /> CITY STATE zip <br /> OW R'S MJML114G ADDRESS (If dKo entfrom Owmar's Address) Ono am <br /> `ISI((—Jt <br /> MAILING ADDRESS CITY S I lJ ZIP <br /> TYPE Of OWNERSHIP: <br /> CORPORATION F-1 INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY COUNTY AGENCY STATE AGENCY❑ FED AGENCY OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID#: ,292 CO-OWNER ID#: ACCOUNT ID#: <br /> COMPLETE THEFOLLOw/NGBUSINESS FACILITY/NFORMArlo <br /> [1, <br /> S this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES NO ❑ <br /> nce.eruc..o <br /> this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ NO ❑ <br /> BUSINESS/FACILITY NAME(This will be the HUSINESSNAMEOn the HEALTH PERMIT) <br /> FACILITY ADDRESS(H FACILITYiS a Moe2EFeioo UNITOr FOOD VEHIC/IAMB the COMMISSARY ADDRESS) BUSINESS PHONES <br /> Z Isay � �(�C.1 �0 % Suite0 <br /> CITY N CILRYISa OBILE FOOD UNITOf F000 VEHICLE DBB the COMMISSARY Cnr1 ST E ZIP <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> M LI G AD E S for H Per/A. /�(N DIFFE ENTfrom FacitityAddmss) Attend Care Of <br /> 1&0, <br /> MAILING ADDRESS CITY /v,111rJ1'VJ' I STATE IP <br /> PC <br /> SIC CODE: APN#: COMMENT: <br /> ACCOUNTADDRESS for fees and charges: OWNER ❑ 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: SIGNATURE: <br /> Please Print <br /> TITLE: DATE DRIVER'S LICENSE# <br /> PHOTOCOPY REQUIRED <br /> Approved By Dale A—nfing otnCe Processing Completed By Db /- zip <br /> / <br /> A PROGRAM{EHD 48-02-034 Pink}or WATER SYSTEM{EHD 46412 %form must be completed for each EHD regulated operation at thla LOCATION, <br /> except UST Program(Use SWRCB forms) <br /> EHD 48-02-035 Mastefile Record-Green <br /> 8119/08 <br />