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SAN JOAF 'N COUNTY ENVIRONMENTAL HEALTH Dr^4RTMENT >STERFILE RECORD INFORMATION FC SHADED SECTIONS FDREHD USE ONLY OWNER ID# hwool 31, 10 CASE# OWNER FILE COMPLETE THEFOLLOw/NG BUSINESS OWNER /NFORMAT/ON.' CHEctr 1F OWNER CuRRENTL Y ON FILE wiTH EH 19 BUSINESSET PHONE: OWNER'S NAME Fvst MI Last BUSINESS NAME(If different from Owner Name) See See orTax ID If OWNER'S HOME ADDRESS CITY STATE ZIP OWNER'S MAILING ADDRESS (If different from Owner's Address) Attention orCare of MAILING ADDRESS CITY STATE zip TYPE OF OWNERSHIP: CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY OTHER❑ FACILITY FILE n pp FACILITY ID#: CO-OWNER ID#: ACCOUNT ID#: RDD3lR COMPLETE THE FOLLOwfNG B U S I N ESS FACILITY/NFORMAT/ON: [1', S this a NEW Business LOCATION Or VEHICLE not preVlOUSiy regulated by the ENVIRONMENTAL HEALTH YES NO ❑ ncowo.ucuro this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ NO BUSINESS/FACILITY A E(This wi the HusiNEss NAmEon the HEALTH PERMIT) t) FACILITY ADDRESS(BFAcitiTyis a MbSxFFOODUN/Tor FWD✓EHiCLEMse the COMMISSARY ADDRESS) BUSHMEBSPHONE '2� 5 �� 2 IUC X162 - 833 Suite# CITU HFauUrvlsa a Fo�oIDI UNIT or F000 VEHICLE use the COMMSSARY CITY) STATFn ^ zip J,r—�� BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 MAILING ADDRESS TOr Health Permft(If DIFFERENTfrom Facility Address) Attention or Care Of MAILING ADDRESS CITY STATE zip SIC CODE: APN#: O O 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 Approved By Date Or I Accounting Office Processing Completed Sy - Dab A PROGRAM(EHD 48-02-034 Pink)or WATER SYSTEM(EHD 464124W.form must be completed for each EHD regulated operation 8t ihis LOCATUN except UST Program(Use SWRCB forms) EHD 48-02-035 Masterfile Record-Green 8/19/08