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SAN JOAr1I'IN COUNTY ENVIRONMENTAL HEALTH PcOARTMENT ,rASTERFILE RECORD INFORMATION F(-.m SHADED SECTIONS FUR EHD USE ONLY OWNER ID# ,p BO-77/-. CASE# i V OWNER FILE COMPLETE THE FOLLOWING BUSINESS OWNERNFORMATION' CHECKIF QWNER CURRENrzrONFILE WnNEHDE1 BUSINESS ON +� 2 OWNER'S NAME �—�F�tMI Cast Z.0 j J BUSINESS NAME(If&ierentftmowner Name) Soe Sec orTax ID# - L L• OWNER'S HOME ADDRESS CITY G STATE ZIP 'L OWNER'S MAILING ADDRESS (If di#erentrMn Owners Address) Attention orCare of MAILING ADDRESS CITY • STATE ZIP 9S Z""""CCJJ � TYPE OF OWNERSHIP: CORPORATION❑ INDIVIDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTYAGENCY❑ STATE AGENCY❑ FED AGENCY❑ O77fER❑ gg FACILITY FILE FACILITY ID#: V CO-OWNER ID#: I ACCOUNT ID#:Oa COMPLETETHE FOLLOWING F M FChis d NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NOthis an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ NO ❑ BUSINESS/FACILITY NAME(This will be the Busr [SSNANean the HEALTH PERMIT) FACILITY ADDRESS(If FAa is a AfbN&EFc UN?Or Fam✓m4 use the CnMMrccecv An,wc«) BUSINESS PHONE �0 C /4 �� O Suite# CITY(if FACILITY IS a MOBILE FOOD UNIT or FOOD VEHICLE use the Cnteso geaY rirv) STATE ZIp� �.�-,CI„\ C-'PM O C4C4L BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 MAILING ADDRESS for Health PerIAIt(If oLFFERENTfrom Facility Address) Attention or Care Of MAILING ADDRESS CITY STATE ZIP SIC COPE: APN#: COMMENT: Ar'rnUNT ALUM SS for fees and charges: OWNER ❑ FACILITY/BUSINESS ❑ RILLING AND COMPI IANCF ACRNnwI Fnr MPNT: 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 ACCOUNT ADDRESS 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 AME' IGNATURE: Please Pent TITLE: �J DATE DRIVER'S LICENSE# [PHOTOCOPY RFOIITREn) Appcoved BY C/'C_ _ OaOe�� / 11 Accounting OfficeProcessing Completed BY Date (� a A PROGRAM {EHD 48A2 034 Pink} or WATER SYSTEM {EHD 46-02-003} form m...t be completed for eadt EHD regulated operation at this 1 OCATION except USI Program(Use SWRCB forms) EHD 48-02-035 Masterfile Record-Green 8/19/08