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SAN JOAC"'V COUNTY ENVIRONMENTAL HEALTH Dr"ARTMENT �W$STERFILE RECORD INFORMATION Foi SHADED SEC77ONSFOR EHD USE ONLY OWNER ID E��z% 1CASE# OWNER FILE OMPLE7ETHEFOLLONQNG BUSINESSOWINERNFORMATrON' CHFarrFOWNER CuRaEAtnronFrLEwrrHEHD❑ BUSINESS PHONE: rJ OWNER'S NAME First Mt Last i BUSINESS NAME(If different from Owner Name) Soc Sec orTax ID# C/ 7`y %o C/ter©G✓ OWNER'S HOME ADDRESS �/ CITY Cl- STATE ZIP OWNER'S MAILING ADDRESS (If difPerentfrom Owner's Address) Attention orCare of MAILING ADDRESS CITY STATE ZIP TYPE OF OWNERSHIP: CORPORATION❑ INDIVIDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ FACILITY FILE FACILITY ID M Co-OWNER ID#: ACCOUNT ID#: COMPLETEEQU92WArNG BUSINESS FACTLrTY ZAEORNA T Is this a NEW BUslness 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 t�ye BusmEysAMmEon the HEALTH PERMIT) o G/�TGN !�� 7,01V �3 FACILITY ADDRESS(IIf FAaLI TYis a AMLEFoco UmTOr FoaD Ya+ro-luse the r—mr—py A--ESS) BUSINESS PHONE b e>K. L�� Suite# CITY(if FAcrurrlsaMOBrLEFOOD UNIrorFOODVE CLE use the COMMISSARYCaYl STATE ZIP To GfG -To BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 MAILING ADDRESS fpr Health Permitif olFFERENTfrom FacllilyAlddress) Attention orCare Of MAILING ADDRESS CITY TSTAT ZIP SIC CODE; APN#: COMrrENT: for fees and charges: OWNER ❑ FACILITY/BUSINESS ❑ rLIr I INr:ANn r_nMPLIANCE Ar-KNowLEnGmFNT; 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 address identified above as the ACCOUNTA—REss 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. PPLICANT'S NAMEN IGNATURE- PfeaSe Print TITLE: DATE DRIVER'S LICENSE# f Approved By �f . Date/p O Accounting Office Processing Compteted By Date /Q 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