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SAN JOAnUIN COUNTY ENVIRONMENTAL HEALTH ncPARTMENT ASTERFILE RECORD INFORMATION FC1..16i s k SHADED SEC17ONS FOR EHD USE ONLY OWNER ID# CASE# OWNER FILE sCOMPLETE THE FOLLOWING BUSINESS OWN E R LY4MRNATYON' CHECKIF OWNER CuRREr nromFrcEwnwEHD❑ BUSINESSHONE- r OWNER'S NAME Q 7-T First - M! Lost i BUSINESS NAME If&Te tfrnmowner Name) Soc Sec orTax ID# 1�A i Z- o IV tv c-, ' OWNER'S HOME ADDRESS s. 'J CITY A 4 4- a' I T - STATE ZIP OWNER'S MAILING ADDRESS (If diJferentfromOwner's Address) Attention orCare of s ' ! MAILING ADDRESS CITY STATE ZIP i TYPE OF OWNERSHIP: F CORPORATION❑ INDMDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ k FACILITY FILE r FACILITY ID#: CO-OWNER ID#: ACCOUNT ID M s ` COMPLETE IS this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No ❑ F Is this an ExrsntNG Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ❑ BUSINESS/FACILITY AME Ljh1s will be the SusmESSArAMEon the HEALTH PERM FACILITY ADDRESS(If FAcltrTris a AfoxLERXv UN.Tqr F000 M.VCLEuse the CQMM,cceRY Anr)PFKr BUSINESS PHONE f 2 d Q 6V - •7A/s?M Zn- L11V Suite# CITY(If FACrurY1S a MOBILE Food UNIT or V use t e C�MMISSAaY CITY} $rte/C ^ ZIP -7 n3 I (y TL/V(/jf`jprY1J [/ k # BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 [MAILING ADDRESS fOr HealM Permit(If DIFFEREIVTfrom Facility Address) Attention orCare Of MAILING ADDRESS CITY =STATE ZIP SIC CODE: APN#: COMMENT: ACCOMEADDoE95 for fees and Charges: OWNER ❑ FACILITY/BUSINESS ❑ Rn k mr;ANr)rmmE iANCF Ac KNOW FDr:MFNT; 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 to me at the 3 address identified above as the AccauNT ADDRESS 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 Please Print TITLE: DATE DREVER'S LICENSE# I Approved By 4' r Date�� . � � � Accounting Office Processing Completed By Date A PROGRAM (EHD 46-02-034 Pink) or WATER SYSTEM {EHD 46-02-003) form mu.Ist 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