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SAN JOAQUI COUNTY ENVIRONMENTAL HEALTH DEP RTMENT ERFILE RECORD INFORMATION FORA SHADED SECTIONS FOR EHD USE ONLY OWNERID# W CASE# OWNER FILE COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION: CHECK IF OWNER CURRENTLY ON FILE WITH EHD BUSINESS PHONE' / /�u OWNER'S NAME 6 lq�! "l —2t� 157 First MI Last BUSINESS NAME(If different from Owner Name) Soc Sec Or Tax ID# o>J �rQ leo OWNER'S HOME ADDRESS ZS S: /fir- t'/ ,. &) oe-L . f)r i CITY b 1 b M lE zip Pj Cyr D OWNER'S MAILING ADDRESS (if different from Owner's Address) Attention or Care of 4 c,v MAILING ADDRESS CITY STATE zip TYPE OF OWNERSHIP: CORPORATION INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY OTHER❑ FACILITY FILE FACILITY ID#: CO-OWNERID#: ACCOUNTID#: COMPLETE THE FOLLOWING BUSINESS FACILITY INFORMATION: G (•D � 7 Isthis a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES NO Eln..,.....c-0 Is this an ExISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ NO BUSINESS/FACILITY NAME(This will be the BuSINE3SNAMEon he HEALTH PERMIT `f i -Z f., Vvti�Q ¢� UN i t OU FACILITY ADDRESS(if FACILITY is a MOBILEFOOD UNnor FOOD VE1HICLEuse the COMMISSARY ADDRESS) Pt�u� BUSINESS GPHONE ��f 2� fVU Direction U111QIt thusl- Suiteit /W 1V 1 1 Z {[5 CITY(If FACILITYIs a MonILE FOOD UNITOr FOOD VEHICLE use the COMMISSARY CITY) STATE ZIP L C' BOARD OF SUPERVISOR DISTRICTOus LOCATION CODE KEYI KEY2 MAILING ADDRESS for Health Perlrllt(If DIFFERENTfrom Facility Address) Attention or Care Of 2 'S r}rV-5Llor-e D ( MAILING ADDRESS CITY r A I u . /1 STAT zip 01 g. SIC CODE: t f/ 4 APN#I:: Zt(' (� I COMMENT: I 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 WIII 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# // n PHOTOCOPY REQUIRED Approved By r nt/, Date /n I'C Accounting Office Processing Completetl By Date l� / A PROGRAM{EHID/418_-02-034 Pink)or WATERVS/YSTEM(EHD 46-02-003)form must be completed for each EHD regulated operation Cat this L/OCATION except UST Program(Use SWRCB forms) EHD48-02-035 Masterfile Record-Green 8119108