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SAN JOAQUIN COUNTY EITXV RONMENTAL HEALTHPARTMENT 10ASTERFILE RECORD INFORMATION FSI SHADED SECTIONS FOR EHD USE ONLY � OWNERID# Do ob�) CASE# OWNER FILE COMPLETE THE FOLLOW/NG BUSI NESS OWN ER INFORMATION: CHEcKIF OWNER CuRrrENTL roN FN.E w1TH EHD❑ BUSINESS An n ,' G a✓C iCk. PHONE: OWNER'S NAME First MI Last S V 9- `f 7— 7,P2. 7 BUSINESS NAME(If different lromOwner Nagle) Soc Sec orTax ID# Ccoil0 a //�� S ✓efHO OWNER'S HOME ADDRESS CITY STATE ZIP OWNER'S AVAILING ADDRESS (If different from Owner's Address) Attention orCare of cl-/z s- $. Go l04 tvt s zf,4 e- 7 1 L of . A- MAILING ADDRESS CITY F&, ers,4 O STAT Zlpa � TYPE OF OWNERSHIP: I CORPORATION❑ INDIVIDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY OTHER❑ FACILITY FILE FACILITYID#: A7.23{a3� CO-OWNER ID#: - -- ACCOUNTID#: U�/7 3(pZ� COMPLETE THEFOLLOW/NG BUSINESS FACILITY/NFORMAT/ON.' IS this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES ❑ NO ❑ n�e.er..—I Is this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ NO ❑ BUSINESS/FACILITY NAME(This will be jhs 71NESS NAMEon the HEALTH PERMIT) 1=G (7hG7� 1J I/Q FACILITY ADDRESS( FACIILcLITYISa/m/o'sitEFdoo UNITor FOOD VEHICLEUSe the COMMISSARY ADDRESS) BUSINESS PHONE Z &, t7 2O J . !7 Ct, f.QStreatNumber Direction , RJ • /Stroat Name Street TypeSuite 9S-9 SA f',f= <?/,FZ. CITY(if FACILITY Is a MOBILE FOOD UNIT Or FOOD VEHICLE use the COMMISSARY CITY) STATE ,y ZIP �^ �,L L A C'1 S 7 1/ 0 BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEYZ MAILING ADDRESS for Health Perm/t(If D/FFERENTfrom Facility Address) Attention orCare Of MAILING ADDRESS CITY STATE ZIP 1I SIC CODE: I APN#: COMMENT: ACCOUNTAODRESS for fees and charges: OWNER X FACILITY/BUSINESS ❑ BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,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: SIGNATURE: Please Print TITLE: DATE DRIVER'S LICENSE# PHOTOCOPY REQUIRED Approvetl By Date Accounting Office Processing Completed By ! Date l� / 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) EHD 48-02-035 Masterfile Record-Green 8/'19/08