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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> „.,rERFILE RECORD INFORMATION FOI,ea„� <br /> SHADED SEmoNS FOR EHD USE ONLY OWNERID# (301) 8 <br /> '1 �Jj CASE# <br /> OWNER FILE <br /> / <br /> COMPLETE THEFOLLOW/NG BUSINESS OWNER/NFORMAT70N. CHECK IF OWNER CURRENTL YON FILE WITH EH DA <br /> BUSINESS PHONE: <br /> OWNER'S NAME <br /> First MI Last <br /> BUSINESS NAME(If diAemnt fmm Owner Name) Soc Seo or Tax ID# <br /> OWNER'S HOME ADDRESS <br /> CITY STATEZIP <br /> OWNER'S MAILING ADDRESS (If different from Owner's Address) Attention orCare of <br /> MAILING ADDRESS CITY STATE zip <br /> TYPE OF OWNERSHIP: <br /> CORPORATION INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY OTHER❑ <br /> FACILITY FILE <br /> FACIUTYID#:L CO-OWNERID#: 7— ACCOUNT ID#:ffiz <br /> !IL <br /> COMPLETE THE FOLLOW/NG BUSIN ESS FACILITY/NFORMA 7YON: G�11. _i.. D 101L� 3139 <br /> r <br /> this a NEW BUSlness LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES NOc r..=.,ro this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ NO <br /> BUSINESS/FACILITY NAME(This will be the SuS/NESSNAMEOn the HLTH PERMIT) <br /> i ?�ur� W111-e (eSEAI *v �- 12oa <br /> FACILITY ADDRESS(if FACILI``TY1,, r <br /> 8 a MOBILEFOODUNITor FQ 'VEHXLEDee the COMI <br /> Ms8 ADORESS) y� fBUSSINES PHONE <br /> 270�� IV GrDOLu t 0-(-T �J Sude IfLV� oC <br /> CITY(HFACIuiYlsa Myel Aogo ytl?Or FOOD VEFNCLE U88 the COMMI55ARYCIT/Y�) STATE rx �� ZIP Y� <br /> BOARD OF SUPERVII/7SORR DISrR1 11CT Ot)LI LorATION CODE [//� KEPI r� KEY2 <br /> MAILING ADDRESS for Hee/th Permd(If DIFFERENTfrom Fac7IIN ddre55) Attemlon orcars Of <br /> 21S S- PRr � ��o^� Q� • <br /> MAILING ADDRESS CITY d I rON\ STATE C q ZIPC7�/�j 3 V/r <br /> SIC CODE: l AJPN O:o o-7 t 2 D I Z COMMENT: lam `1 <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 t0 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 Prnt <br /> TITLE: DATE DRIVER'S LICENSE# <br /> PHOTOCOPY REQUIRED <br /> Approved BY V Date r 1 ( Accwntlng Office Prot ing Cwnpleted BY DW r / <br /> A PRoGR*w(EHD 48-02-034 Pink)or WATER SYSTEM(EHD 46-GZA4411orm must be completed for each EHD regulated operation at tMt s LOCA/TIOK <br /> except UST Program(Use SWRCB forms) <br /> EHD 48-02-035 Masterfile Record-Green <br /> 8/19/08 <br />