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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> ERFILE RECORD INFORMATION FOF <br /> - <br /> "It <br /> SHADED BECKONS FOR EHD USE ONLY OWNER ID -wCASE# <br /> OWNER FILE <br /> COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION. CHEcKiF OWNER CuRREmnyoNFrLE wrrHEHDO <br /> BUSINESS 7?OV 0 PHONE: <br /> k OWNER'S NAME <br /> First M1 Last <br /> BUSINESS NAME(if different from owner Name) SOC Sec orTax ID# <br /> OWNER'S HOME ADDRESS 3 lNllvY 41- <br /> CITY 041 STATE zip Y5 Z3 0 <br /> OWNERS MAILING ADDR (If difTe tfi Owner's Address) ffnt:!on orcare of <br /> EF 0 0'30 /,!V— <br /> MAILING DDRESS CITY S 7 ZIP <br /> -j <br /> TYPE OF OWNERSHIP: <br /> CORPOPATIONE] INDIVIDUAL PARTNERSHIP[:1 LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY E] FED AGeNcYE1 OTHERE] <br /> FACILITY FILE <br /> FACILITY ID#: CO='OWNE ID ACCOUNT}D <br /> COMPLETE THEFOILowiNG BUSINESS FACILITY INFORMATION: <br /> Is this a NEW Business LOCATION orVEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT',.), YES El No El <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? Yes ❑ No ❑ <br /> BUSINESS/FACILITY NAME(This will be the BuszNEssNAmEon t} <br /> le <br /> 0 <br /> FACILITYADDRESS(If FAcn-r7_yIsa M1bffLEFcoDUNrror'W vl�l <br /> _7fu <br /> :?-,9 Iq 3 Altv V *&CommissARY Awkess) BUSINESS PHONE <br /> Sheet Number Dirmton Sb-get Name Street TVDL' suite <br /> CITY(If FAcajTyis a MoR&F FooD UNIT or FOOD VFHio use the COMMISSARY C STATE zip <br /> 9S- <br /> BOARD OF SUPERVISOR DIESTRI�r�1� �v LOCATION CO EY T, <br /> MAiuNG ADDRESS for Health Permit(iifDiFFERENTfrom FOdRYAddreSs) Attention or Care Of <br /> MAILING ADDRESS CITY STATE zip <br /> SIC CODE: 'APN#: <br /> ACCOUNTAIDDAESS for fees and charges: OWNER ❑ FAcILITYlBUSINESS ❑ <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,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 ACCOUNTADDRESS 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 COUNTYOrdinanceCodes and/or Standards and STATE and/or <br /> FEDERAL Laws and Regulations. <br /> APPLICANT'S NAME.- SIGNATURE: <br /> Please AYnr <br /> TITLE: DATE DRIVER'S LICENSE# <br /> PHOTOCOPY REQUIRED) <br /> � <br /> Approved By 'D ate .. Processing Completed By <br /> I <br /> Date ,-! <br /> a�f <br /> A PROGRAM (EHD 48-02-034 Pink WATER?S�ym {EHD 46-02-003} form must be completed for each EHD regulated Opera 'on �at this <br /> LOCATION except UST Program(Use SWRCB forms) <br /> EHD 48-02-035 Masterfile Record-Green <br /> 8/19/08 <br />