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SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT �%.rASTERFILE RECORD INFORMATION FG... , SHADED SECTIONS FOR EHO USE ONLY OWNER ID# I R O/ OWNER FILE OMPCETE THE FOLLOWING USINESS WN NFORMATION. CNECKIFOWNER CuRRENnroNrrLEwrnv EHD❑ BUSINESS OWNER's NAME PHONE: Fist M/ Lasf BUSINESS NAME(If dilrnmthrwn Owner Name) SDC Sec orTax ID# of G OWN ERIS HOME ADDRESS FrVT Fd CINSTATE ZIP S 3 Q OWNER'S MAILING ADDRESS (If di t ftm Owners Address) Attention orCam of MAILING ADDRESS CITY STATE LP TYPE OF OWNERSHIP: CORPORATION❑ INDIVIDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ FACILITY FILE FACILITY ID CO.OWNER ID#: ACCOUNT ID 1I:49 Q N M 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 Ne Busu,E Nweon Lhe HEALTH PERMIT) O ' Q O rV FACILITY ADDRESS(If FACT! rvisa Mbwt Fc UNTror FWv Vc tr use the ci awgcmr Anw BUSINESS PHONE s77oLQF_/N -1'p/&n 7;f41 iS�v surea CITY(RFACfUTY1a MO&LE FOOD UNIT Of FOOD VEHICLE Use the CQIAASSMY Cm) STATE ZIP BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 MAILING ADDRESS for Health Perm/tof D(FFERENTfrom Fe 111),Addr ) Attention orCare Of MAILING ADDRESS CITY STATE ZIP SIC CODE: APN#: COMMENT: drrnrrArrd REBS for fees and Charges: OWNER ❑ FACILITY/BUSINESS ❑ Ru I INT AND COMPLIANnF ACRNnWLcnr.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 t0 me at the address identified above as the ACDOUNr AnoRFss 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' SIGNATUREw F/ease Print TITLE: DATE DRIVER'S LICENSE# Ap"OYed C Date Aamuming ornae Processing Completed By Data 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 I OCATION except UST Program(Use SWRCB forms) EHD 48-02-035 Masterfile Record-Green 8/19/08