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SAN JOAQIJj OUNTY ENVIRONMENTAL HEALTH DEATMENT ERFILE RECORD INFORMATION FOR SHADED SECTIONS FOR EHD USE ONLY OWNERID# (/�f1r. 1 /00 gp1O/,V CA3E# OWNER FILE COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION: CHECK IF OWNER CURRENTLY ON FILE wITH EHD BUSINESS PHONE: OWNER'sNAME rI _O/�b� First MI Last U U BUSINESS NAME(If different from Owner Name) SOO Sao Or Tax ID# M er- i (,arJ To -) e(- OWNER'S HOME ADDRESS P, I) , `J 636 c5 CITY 6-e ` I •I s F'L zIP S-o OWNER'S MAILING ADDRESS (if differentfrom Owner's Address) Attention or Care of Z� L MAILING ADDRESS CITY STATE zip TYPE OF OWNERSHIP: CORPORATION XINDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY OTHER❑ FACILITY FILE FACILITY ID#: CO-OWNER ID#: ACCOUN/T ID#: COMPLETE THE FOLLOWING BUSINESS FACILITY INFORMATION: C E-�S D ( ()�06 2 [isNEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES NO ❑r�rn EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ NO ey, BUSINESS/FACILITY NAME(This will be�aUS/NESSNAMEOn the HEALTH PE MIT) Affl,V'ILAN LDv ler S - A eLA NDr�� — Ob FACILITY ADDRESS(If FACILITYis a MOeILEF000 UNITor FOOD VEHICLEuse the COMMISSARY ADDRESS) BUSINESS PHONE Il7� � Q, -Sob 41A ( 4INp Lo _ (�p2 Z0�( 'OZ � Suite# CITY(If FACILITYIs a MOB�FoOD UNITOr FOOD VEHICLE use the COMMISSARY CITY) STAT�.� A ZIP � -Y, BOARD OF SSUUPEERVISSOR DHSS lT(RICTT�D* LOCATION CODE 9157 KEY1 KEY2 MAILING ADDRESS for�ealth Pe It(If DIFFERENTfrom Facility Address) Attention or Care Of ( Y. 6 D $ a- MAILING ADDRESS CITY LA p e N ( K STATE Z f SIC CODE: L4 (I 13 APN#: Z Q 8 io /^-t D ►U 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 t0 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 ay (j�/ Dale (2 Z 3 ( 3 Accounting Office Processing Completed By Date I A PROGRAM{EHD 48-02-034 Pink)or WATER SYSTEM(EHD 46-02-0031 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