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SAN.TOA UIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT JOA RECORD INFORMATION F* SHADED SECTIONS FOREHD USE ONLY OWNER ID# v 7 lt�o�Q�95CASE# OWNER FILET COMPLETE THEFOLLOw/NGBUSINESS OWNER /NFORMAT/ON: CHEctrtF OWNER CURRENTL VON FILE wiTH EHD❑ BUSINESS Aos Q, l PHONE: OWNER'S NAME Fust M/ Last �15—9 �OQO USINESS NAME(If different tromOwner Name) Soc Sec orTax ID# VG4�.e?ytnSan St NeOf4oir;ac S)fA�,l OWNER'S HOME ADDRESS `v CITY n iha)MM S 21P Ctl"II✓ OW R'S MAILING ADDRESS (If d' tfrom0 er's Address) tion arcane of C. MAILING ADDRESS CITY ^ E ZIP `�q q )I ZO TYPE OF OWNERSHIP: CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY OTHER❑ FACILITY FILE ¢q(� FAaurvlD#: ��I S CO-OWNERID#: ACCOUNT ID#: O03 G 6 S COMPLETE THEFOLLOw/NG BUSINESS FACILITY INFORMATION.' Is this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YESX NO ❑ nce.e.ucuro Is this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ NO SINESSIFACIILNAiME(This wZthHEPTH ERMIT) 1 LIAL -MU FACILITY A(DRESS(HFACILITis a MboxEFOCO UNIT-or F�VEHICLEIfae Cthee COMMISSARY DRESS) /II-,1 BUSINESS PHONE (/l/t /W//ll ('-//v/1 I—/JIh/J,L(./fll.^IY/^/I(' suite# �10LELUIZ�o CITY(If FADIL?YIS a MOBILEF60D UNRor FOOD VEHICLEuse the COMMISSMYCDY) STATE ZIP g5ZLIZ BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY( KEY2 MAILING ADDRESS for Health PerMfi f D/FFERENTfmm Faci/ityAddresa) Attention arcane Of MAILING ADDRESS CITY STATE ZIP SIC CODE: APIN#:o11� ��(]r� 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 1 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 AccounbW Office Processing Completed By A PRoGRAw(EHD 48-02-034 Pink)or WATER SYSTEM(EHD 464)2 MkQj form must be completed for each EHD regulated operation at this LOCATIM except UST Program(Use SWRCB forms) 8/19/08 02-035 /'t n ) 'rl I I I 1 Masterfile Record-Green