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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MAIL ERFILE RECORD INFORMATION FORM—� SHADED SECTIONS FOR EHD USE ONLY OWNER ID III 04)00,20E-14- 4 00i ,204-1v - CASE# V OWNER FILE COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION: CHECK IF OWNER CURRENTLY ON FILE wlrH EHD❑ BUSINESS �V E S O (PHONE: OWNER'S NAME First MI Last BUSINESS NAME(If dh7brent from Owner Name) SOC Sao or Tax IDIr # OWNER'S HOME ADDRESS CIT/ f�— \Q -� STATE ZIP 0%,�;2\S OWNER'S MAILING ADDRESS (If different from Owner's Address) Attention or Care of obs-4 MAILING ADDRESS CITY STATE ZIP TYPE OF OWNERSHIP: II�� CORPORATION ElINDIVIDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FEU AGENCY OTHER❑ / FACILITY FILE FACILITY ID#: opzz S6 CO-OWNERID#: ACCOUNTID#: COMPLETE THE FOLLOWING BUSINESS FACILITY INFORMATION: F this aNEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES NOthis an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ NO a. BUSINESS/FACILITY NAME(This will be the BUSINESS N"Eon the HEALTH PERMIT) S a Tj\5l. O.S ce\Z V FACILITY ADDRESS(K FACILITY l�a as�M� O�BI�LE�"F"OOD UNITor FOOD VEHICLE use the COMMISSARY ADDRESS) BUSINESS PHONE S6bV" A,9 AWGlr/I/Z Street Number DIh. Street Name SI-1 T.— suite# CITY(if FACILITY*a MOBILE FOOD UNITor FOOD VEHICLE use the COMMISSARY CITY) STATE zip BOARD OF$UPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 MAILING ADORESa for Health Permft(If DIFFERENTfrom Facility Address) Attention or Care Of MAILING ADDRESS CITY STATE zip SICCODE: %-\ t \: APNtI: COMMENT: ACCOUNTADDRESS for fees and charges: OWNER FACILITY/BUSINESS ❑ 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 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 � p Approvetl By :'A` . !�ryLL Date t f_ ii_ / � Accounting Office Processing Completed By / /'� Date .[/� / 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