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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT `1lil,ASTERFILE RECORD INFORMATION FcA.A SHADED SEC ms FOR EHD USE ONLY OWNER ID# pw p !l 3 CASE#_ OWNER FILE COMPLETE THEFOLLOwING BUSiN ESS OWN ER INFORMATION: CHECK IF OWNER CURRENTLYON FILE wiTHEH D❑ BUSINESS 7— r�HONE: OWNER'S NAME �Q 'V4 57—.2 Fr First Mf Last BUSINESS NAME(If different fromowner Name)) Soc Sec orTax ID# /'er" 5 I• OWNER'S HOME ADDRESS CITY S�G C Gc O�! STAe- ZIP Q 7F 2 O 3 OWNER'S MAILING ADDRESS (If different from Owner's Address) Attention orCare of [ '305 - F -F-Fe- v� a id, 217e, roc MAILING ADDRESS CITY C�G e z<� STTATE ZIP p r g O TYPE OF OWNERSHIP: 7 19 I r� CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY OTHER❑ FACILITY FILE FACILITY ID#: '7=Zj CO-OWNER ID#: ACCOUNT ID#: (j COMPLETE THEFOLLOWINGBUSINESS FACILITY INFORMATION. Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES ❑ NO ❑ rteo�cata.rut9 Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ NO ❑ BUSINESS/FACILITY NAME(This will be the 0u&NES8 NAMEon the HEALTH PERMIT) FACILITY ADDRESS(If FAcurTYis a MOBILE FOOD UNfror FDov VEHICLE USS the COMMISSARY ADDRESS) BUSINESS PHONE 1/4 Suite# CITY(If FActuT-yIS a MOBILE FOOD UNIT or FOOD VEHICLE use the COMMISSARY CITY) STATE ZIP BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 :FKEY2 MAILING ADDRESS for Health Permit(If DIFFERENTfrom FacilityAddress) Attention crCare Of MAILING ADDRESS CITY STATE Z!P S I�Cul APN#: LiOMMENr: ACCOUNTADDRESS for fees and charges: OWNER ❑ FACILITYIBUSINESS ❑ 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 ACCOUNTADDRFSS 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: In /1 e G SIGNATURE: Please Print TITLE' D! s R 4C17 r r DATE 1 �Q�� PRHOTOCOPY REQUIRED) Approved By Date Accounting Office Processing Completed By A PROGRAM(EHD 48-02-034 Pink)or WATER SYSTEM(EHD 46-02-003)form must be completed for each EHD regulated operation at this LOCATION except UST Program(Use SWRCB forms) G( EHD 48-02-035a f f Gl�lf/ Q��O L �"tJ a{/t ` r Lo j(/1 Masterfile Record-Green 8119108