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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT OSTERFILE RECORD INFORMATION Foe SHAADEAD SECDONS FOR EHD USE ONLY/ /OWNER ID# CASE# G f—' " T b f ( 01 13 Ej,s l OWNER FILE COMPLETE THEFOLLOw/NG BUSINESS OWNER /NFORMAT/ON.- CHECK/F OWNER CuRRENTL r oNFILE wiTH EH DO BUSINESS PHONE- / OWNER'S NAME Firsf MI Last BUSINESS NAME(If different fromOWner Name) Soc Sec orTax ID# � e—r' 2UT,� Nor -efts CA OWNER'S HOME ADDRESS 2 S ( A'f'V— CITY 6� SeA zip OWNERS MAILING ADDRESS (If different from Owner's Address) Attention orCam off. �-1 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-OWNER ID#: ACCOUNT M#: COMPLETE THEFOLLOw/NG BUSI NESS FACILITY/NFORMAT/ON: I-ss-t s a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES � NO ❑ s an FxISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ NO SK BUSINESS/FACILITY NAME(This will he the flus/KEssNAME n tLTH PE IT) r �z oN Wtire �ehe�HEAW 9f 12 FACILITY ADDRESS(if FAc1vTYJg a MOBILEFOOo UMror FOOD VEHICLEYs9 the COMMISSARY ADDRESS) BUSINES PONE I v4wbQr b T� C I X3u �q�2c�r b n a Suite# CITY(if FAclurns a MOBILE FOOD UNIT Or FOOD VEHICLE use the CoMMissARY Cm) STATED zip e L BOARD OF SUPERVISOR DISTRICTS LOCATION CODE AA KEY1 KEY2 MAILING ADDRESS for Health Permit(if DIFFERENTfrom Faci/ityAddressJ Attention arcane Of 2S grlGSL, ar<—, pf MAILING ADDRESS CITY !`1 J C L) _ STAT,c SIC CODE: V APPN`#: 2 /i V` D COMMENT: l.- 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 tome 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 andfor FEDERAL Laws and Regulations. APPLICANT'S NAME: SIGNATURE: Please Print TITLE: DATE DRIVER'S LICENSE# ///111 PHOTOCOPY REQUIRED Approved By Dale {1 ' Aeeaunung Office Proceasing Cwnpleted By Date A PRoGRA*(EHD 48-02-034 Pink)or WATER SYSTEM{EHD 46.02.YIIIIIIII.tiornr mrlstlao completed for each EHD regulated operationatthis LOCATION, exceptexcept UST Program(Use SWRCB forms) EHD 48-02-035 Masterfile Record-Green 8/19/08