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SAN .JOA' 'N COUNTY ENVIRONMENTAL HEALTH r`"ARTMENT <br /> -"ASTERFILE RECORD INFORMATION FOmF <br /> SHADED SECTIONS FOR EHD USE ONLY OWNER ID# pO2 CASE# <br /> OWNER FILE <br /> OMPLETE THE FOLLOWING EJUSINESS QWNER77 CHECAIFOWNER CURRENTZYONFILEWITNEHD❑ <br /> BUSINESS HON=A n /D O <br /> OWNER'S NAME Z S Z ? 9 e <br /> Fist M/ Last <br /> BUSINESS NAME(If dNfe'entfr Owner Name) SOC Set OrTax ID# <br /> jzvo✓ dvll r GcsS /.ry G <br /> OWNER'S HOME ADDRESS Z78'-5 Mi7'C/4 E L G /J/C; 049fr 7 <br /> CITY WR / G,`F C STATE ZIP Tj <br /> OWNER'S MAILING ADDRESS (If di/femntfrom Owners Addres) Attention orCare of <br /> MAILING ADDRESS CITY STATE ZIP <br /> TYPE OF OWNERSHIP: <br /> CORPORATION❑ INDMDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ <br /> n�7 +cJ� FACILITY FILE <br /> FACIDTY ID M;fysy/ CO-OWNER ID If: ACCOUNT ID#: �PD. ��f <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 /> BustNEss/FaatlTr (This will beveBufovm/WrEon heH PERMIT) <br /> r/ r_ <br /> FACILITY ADDRESS(IfFACILITY` <br /> ; qaF EfCYv - F �M�e eA;? s �CzNE <br /> sous a <br /> CITY(If FALILlIYied MoelLEFo`ooiNlror FooqD" ZIP (77// `J <br /> / S <br /> BOARD OF SUPERVISOR DLST1UCr LOCATION CODE KEY1 KEY2 <br /> MAILING ADDRESS for Health Perm/t(If DIFFERENTfrom Fad/ih AddMSS) Attention or Care Of <br /> MAILING ADDRESS CITY STATE ZIP <br /> SIL CODE: B q Am#: 83/BO�3 <br /> drr'nitArT'dnneFee for fees and charges: OWNER ❑ FACILITYIBUSINESS ❑ <br /> &I Nn ANn r.oMpl iANcF Af.NNnwl Fnr,MFNT; 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 tome at the <br /> address identified above as the A. .D wrr ( T AnDREcc 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 Re ulations. <br /> PPLICANT'S NAMP NA E' <br /> Please Pnnt <br /> TITLE: DATE DRIVER'S LICENSE# 1 <br /> Approved By Date A--ndng Oltlte Proeessi Completed BY Date ( I <br /> A PROGRAM {EHD 48-02-034 Pink} or WATER SYSTEM {EMD 46-02-003} form Daunt be completed for eatb EHD regulated operation at this <br /> I0CATTO except UST Program (Use SWRCB forms) <br /> EHD 48-02-035 Masterfile Record-Green <br /> 8/19/08 <br />