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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT I`, TERFILE RECORD INFORMATION FOF- 3 � r SHADEDSECTIONSFOREHD USE ONLY OWNER ID# BO /� �Qr� CASE# OWNER FILE COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION.' CHEcKrF OWNER CURRENTIYON FILE wrrH EHD❑ BUSINESS G PH NE: OWNER'S NAME First MI Last U� r BUSINESS NAME(If different from Owner Name) SoC Sec OrTax Io OWNER'S HOME ADDRESS A CITY D O STATE ZIP 7 OWNERS MAILING ADDRESS (If dtVevent from Owner's Address) Attention or Care of �J MAILING ADDRESS CITY STATE ZIP TYPE OF OWNERSHIP: CORPORATION❑ INDMDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ FACILITY FILE FACILITYID#:. & _ CO-OWNER ID#:_ ACCOUNT ID#:.Z,9Q _ COMPLETE THEFOLLOWING BUSINESS FACILITY INFORMATION; Is this a NEW Business LOCATION Of VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO ❑ Is this an DaSTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ NO ❑ BUSINEss/FACILITYAME(This will be BOsrxtss on the HEALTH PERMIT) FACILITY ADDR 6(I�O �s a �UrvI.ori ro IMthe fom ILSs av BUSIN 1 ��^E 3 ShEe[Number Dlnrtlan Street N fJ Sulfe# CITY(If FACILITY is a Moet FoOODU 7A rFOOD VE ict use the Comiassanv Cml ST Y T E ZIP r'Z ILD BOARD OF SUPERVISOR DMMCT LOCATION CODE KEY1 KEY2 MAILING ADDRESS for Health Permit(If DLFFERENFfrom Fadl¢yAddress) Attention or Care Of MAILING ADDRESS CITY STATE ZIP SIC CODE; APN#: CoMMEm: .ACCOUNTADD IEW for fees and charges: OWNER ❑ FACILITYIBUSINESS ❑ BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and acknowledge that all PERM?FEES,PENALTIES,ENFORCEMENT CHARGES and/Or HOURLY CHARGES associated With this operation Will be billed to me at the address identified above as the AccouArTADDREss 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 Pdnt TITLE: DATE DRIVER'S LICENSE# PHOTOCOPY REQUIRED) Approved By Date rj/ ,,./ A¢vunting Office Processing Completed By L /O Date G, y� I I Sy � L� O �1 7 A PROGRAM {EHD 48-02-034 Pink) Or WATER SYSTEM {EHD 46-02-0031 form must be Completed for each EHD regulated operation at this LOCATION except UST Program(Use SWRCB forms) EHD 48-02-035 Masterfile Record-Green 8/19/08