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SAN JOAOI'IN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT L STERFILE RECORD INFORMATION FOr . SHADED SECTIONS FOR EHD USE ONLY OWNER ID;-T CASE# OWNER FILE COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION: CHECK IF OWNER CURRENTLY ON FILE wITH EHD❑ BUSINESS - PHONE: OWNER'S NAME C First MI Last L BUSINESS NAME(If different from Owner Name) SOO Sec or Tax ID# 1 ce OWNER'S HOME ADDRESS y St CITY zip OW/N�EE�R's MAILING ADOR SS If different from Owner'a Address) Attention or Care of ✓L�l//L. W l� Imiks MAILING ADDRESS CITY R p n�.I^ E zip /� TYPE OF OWNERSHIP: lit I(�{ ' "I CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY STATE AGENCY❑ FED AGENCY OTHER❑ FACILITY FILE FACILITYID#: C) yttCO-OWNERID#: ACCOUNTID#: COMPLETE THE FOLLOWING BUSINESS FACILITY INFORMATION: Y��jj�rrr [Is th,S a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES gl NO.e .this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES39 NO ❑ SINES /FACILITY N 77C,,,will be the BUSINESS NAMEon the HEALTH PERMIT) S FACILITY !A\D/D,RESS(If FACILITY is a MOBILE F�IooD(U�NI Toolr FFwD VEHICLLE uvse'thecCOMMMISSISARY'AIDDRESSI BUSINESS PHONE /dVV P" wld CWI It�1J 6 U(J Street Type Suite# — — 2— CITYVACaITYisa MOBILE FooD UNIT or FOOD VEHICLE use the COMMISSARY Cn-Y) STATE ZIP 9S�3 �1 J BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 MAILING ADDRESS for Health Perfrllt(If DIFFERENTfrom Facility Address) Attention or Care Of MAILING ADDRESS CITY STATE zip SIC CODE: APN#: COMMENT: ACCOUNT ADDRESS for fees and charges: OWNER ❑ FACIUTYIBUSINESS 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 Approved By Date Accocngng Office Processing Completed By/ X C G.. Q AAT 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