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SAN.JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT i ERFILE RECORD INFORMATION INFORMATIONFO SHADED SECTIONS FOR EHD USE ONLY \V s / / Q ? / Q.LJ -C„A SE# OWNER FILE COMPLETE THEFOLLOw/NG BUSINESS OWNER /NFORMAT/ON.' CHEcK IF OWNER CuRRENTZ Y ON FiLE wiTH EHD BUSINESS PHONE: OWNER'S NAME First MI Last BUSINESS NAME(If different from Owner Name) SOC SCC or Tax ID# OWNER'S HOME ADDRESS CITY STATE ZIP OWNER'S MAILING ADDRESS (If different from Owner's Address) Attention orCare of MAILING ADDRESS CITY STATE zip TYPE OF OWNERSHIP: CORPORATION INDIVIDUAL❑ PARTNERSHIP[:1LOCAL AGENCY❑ COUNTY AGENCY ElSTATE AGENCY[:1FED AGENCY OTHER❑ FACILITY FILE FACILITY ID#: CO-OWNER ID#: �7 .-{-V-ACCOUNT ID COMPLETE THEFOLLOw/NG BUSINESS FACILITY/NFORMAT/oN: f LJS U �r D Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES g_I. NO ❑ nce.oTucuro � " Is this an ExISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No BUSINESS/FACILITY NAME(This will be the @DaiNEssNAYEon the HEALTH PERMIT) r PS1ZlT1J re �a� CoLiai�u�A FACILITY ADDRESS(N FAcanvle a Aroa/LEFOOD URiror F000 VEH/CLEUse the COMMISSARY ADDRESS) BUSINESS PHONE l LI�00ahon E . (>� N 8� suite# 4366 -Z�f I CIN(If FAclurYls a MOBILE D UNROr FOOD VEHICLE OSe the COMMISSARY CfrY) STA ZIP S^G 3 ( 1L2 r J( BOARD OF SUPERVISOR DISTRICT)o LOCATION CODE KEY1 KEY2 MAILING ADDRESS for Hea/UT PeHill`D/FFERE Tfrom Faci/ityAddmss) Attention o Care Of 22 4r�2. ��ore jr MAILING ADDRESS Cl STAT ZIP SIC CODE: LA `65 I APN#:0 �bo COMMENT: ACCOUNTADDRESS for fees and charges: OWNER ❑ FACILITY/BUSINESS BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that 1 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 tome 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: SIGNATURE: Please Print TITLE: GATE DRIVER'S LICENSE# //--�� PHOTOCOPY REQUIRED / APPrareA BY 1 / Data l /l1 I Accmming office Processing CmlPlet By Data r A PROGRAM{EHD 48-02-034 Pink)or WATER SYSTEM{EHD 4fi-D2A4%.form. wl be completed for each EHD regulated operation at this ILOCATO►4 except UST Program(Use SWRCB forms) EHD 48-02-035 Masterfile Record-Green 8/t9/O8