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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT P STERFILE RECORD INFORMATION FOF SHADED SECTIONS FOR EHD USE ONLY OWNER ID# ' ' CASE# — OWNER FILE COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION: CHFmw OWNER CURRENn r oN FILE wmr EHD❑ BUSINESS WE OWNER'S NAME 3O First MI Last BUSINESS NAME(if d/ferent hom owner Name) Soe Sec orTax ID# Ahl OA VI _/ VIV? OWNER'S HOME ADDRESS d , . c✓oT T S 6 CITY -r !L' /J /1 I STATE LP OWNER'S MAILING ADDRESS(If dRerentfran owners Address) Attention orCare of 19 g 7 R ,r VIS=W n� MAILING ADDRESS CITY G STATE ZIP TYPE OF OWNERSHIP: IF ,J CORPORATION❑ INDMDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ FACILITY FILE FACILITY ID#:® 9)Ila IQ CO-OWNER ID#: ACCOUNTIDM COMPLETE THE FOLLOWING BUSINESS FACILITY INFORMATION: Is this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO ❑ Is this an ExIsTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ NO ❑ BUSINESS/FACILITY NAME(This will be the Bustvt NAHE the HEALT ) S J c rr « lv6A 14S 1/:,/ L- 77 - lv:L /n�So� /�/ 4/✓O!L 3 FACILITY ADDR If FAc Is a Mb&T Fav Uvrror F'a Ve use thre� r ) S . 's e. TAsT vl �W /J� BUSINESS PHONE SawNum r St!AW N Ti Suite# CITY(If FA GU TY Isa dostiE FOOD UNITor FOOD VEHIcL use the COMMIssmy CRY) STAT, ZIP ' Tc� l�Toni C%�4 9SZ a 7 BOARD OF SUPERVISOR DISTRICT LOGTION CODE KEV'I KEY2 MAILING ADDRESS for Health Permit(if DIFFERENTfrom FadrityAddress) Attention or Care Of MAILING ADDRESS CITY STATE ZIP SIC CODE: APN#: COMMEM: ACCOUNTADDR£SB for fees and charges: OWNER ❑ FACILITY/BUSINESS ❑ BILLING AND COMPLIANCE ACKNOWLEDGMENT: t,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 t0 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 DRIVEWs LICENSE# PHOTOCOPY REQUIRED) Approved Byy .�!//)/ Date•r 2 ' Q 11 ADDO nting Office Processing Completed By 48- Date / A PROGRAM (EHD 02-034 Pink} or WATER SYSTEM (EHD 46-02-003} form must be completed for each EHD regulated operation at this LOCATION except UST Program (Use SWRCB forms) EMO 48-02-035 Mastemle Record Green 8/19/08