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SAN.JOP^'IIN COUNTY ENVIRONMENTAL HEALTH r-PARTMENT <br /> -MASTERFILE RECORD INFORMATION FOmO <br /> SHADED SECTIONS FOR EHD USE ONLY OWNER ID# pDl.SSL� ! CASE# <br /> OWNER FILE <br /> OMPLErE THE FOLLOWING OUSINESSOWN ER NFORMATlON' CNECKIF OWNER CURREAfn YON FRE W:rrNEHD❑ <br /> BUSINESS PHONE:q <br /> OWNER'S NAME11 —Frst MI Last / ` <br /> BUSINESS NAME(If dfrEYEntfmm Owner Name) SOC Sec arTax ID# <br /> D <br /> OWNER'S HOME ADDRESS <br /> CITYSTATE LP Tlql�0,12 <br /> OWNER'S MAILING ADDRESS (If dlKerenf Owner's Address) Attention or Care of <br /> MAILING ADDRESS CITU ! <br /> TATE ZIP <br /> TYPE OF OWNERSHIP: <br /> CORPORATION❑ INDIVIDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OfHER❑ <br /> ` FACILITY FILE <br /> FACILITY ID#' QQ/ p r�( zC CO-OWNER ID If: ACCOUNT <br /> IS this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO ❑ <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ❑ <br /> BUSINESS/FACILITY NAME(This will be the BNSTNNASSAGNEon the HEALTH PERMIT) <br /> �L c.ar� vv <br /> FACILITY ADDRESS(If FAQurris a Nic&A,FcvUNirorz F' VFwat:use the rnmmrccevAmoccc) BUSINESS PHONE <br /> /5- 900 �ifTF ST <br /> nl� Suite,# <br /> CITY(If FACILITYIs a M pt1(ryr r ODVEHICLeusethe COWASS ,_.=Y COv) STATE ZIP <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY) KEY2 <br /> MAILING ADDRESS for Heath Permit Ir DIFFERevrfrom Fa RyAddn ) Attention orCare Of <br /> MAILING ADDRESS CITY STATE ZIP <br /> SIC CODE: APN#: Igo COMMENT: <br /> drrnrrArr 4DDRESS for fees and charges: OWNER ❑ FACILITY/BUSINESS ❑ <br /> R11 I ING ANo rQMP1 IANrP ArRNowLcnQMFNT; I,the undersigned Applicant,certify that I am the Owner, Operator,or Authorized Agent of this Business,and <br /> I acknowledge that all PERMIT FEES, PENALTIES, ENFORCEMENT CHARGES and/Or HOURLY CHARGES associated With this operation will be billed to me at the <br /> address identified above as the ACCOUNT AnORFSS for this site. I also certify that all information provided on this application is true and correct; and that <br /> all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or <br /> FEDERAL Laws and Regulations. <br /> PPLICANT'S AME' SIGNATURE! <br /> Please Pnnt <br /> TITLE: DATE DRIVER'S LICENSE# <br /> (PHOTOCOPY Rmuigm) <br /> ,roved By pare !� ,lyAnmuming Office Processing Completed BY Date a4 <br /> A PROGRAM (EHD 48-02-034 Pink} or WATER SYSTEM (EHD 46-02-003) form must be completed for each EHD regulated operation at this <br /> I OCATION except UST Program(Use SWRCB forms) <br /> ENO 48-02-035 Masterfile Record-Goren <br /> 8/19/08 <br />