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SAN .JOAN COUNTY ENVIRONMENTAL HEALTH APARTMENT STERFILE RECORD INFORMATION F SHADED SECTIONS FOR EHD USE ONLY OWNER ID# I CASE # OWNER FILE COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION. CHECK/ie OWNER CURRENnYON FILE W/THEHD❑ BUSINESS OWNER'S NAME Lt.r-T L -C- t L PHONE: 5" First MI Last BUSINESS NAME (If dHlerent bOmOmer Name) SMW-f-por.JI x Soo Sac orTax ID # OWNER'S HOME ADDRESS 1-313 CITY 12�Ac STAT zip '1.-3 77 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 FACILITY ID #:f I\GLS '1�L"1 Co -OWNER ID# AccOUNTID#:A-Q,a0 5 5 :OMPLETE THEFOLLOw/NG BUSIN ESS FACILITY INFORMATION.- Is NFORMATION.Is this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH n—.a..1-9 Is this an E%ISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ NO BUSINESS/FACILITY NAME (This will be the Sus/NESs N"Eon the HEALTH PERMIT) .SMOG-T-P-IjNI t, FACILITY ADDRESS (H FACILITY I s a MOaILEFOOD UN/Tor FOOD VEHICLEO9e We COMMISSARY ADDRESS) `7 189 W L+k� \ C—;?- try Sue ts CITY (If FAoLmis a MosILEFOOD UNrror FOOD VEHICLE use the CouMIssARY C")i STAT S-1-0 C, K-ro tj BOARD OF SUPERVISOR. DISTRICT LOCATION CODE KEY1 YES ❑ NO K KEY2 BUSINESS PHONE ZP MAILING ADDRESS for Health Permlt(If DIFFERENTfrom Facility Address) Attention ot-Care Of MAILING ADDRESS CITY STATE zip SIC CODE: APN#: 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 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 Reoulations. APPLICANT'S NAME: SIGNATURE: \ �1-" 17 'r Li— PleasePnnl l yJ [� ��+� _ Approved By Data Accounting Mee Proceaaing Completed By / .Q ( Data I A PROGRAM (EHD 48-02-034 Pink) or WATER SYSTEM (EHD 4602-003) 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