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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH D;=QARTMENT <br /> TERFILE RECORD INFORMATION Fok"',,,) <br /> SHADED Smms FOR EHD USE ONLY OWNER ID# <br /> OWNER FILE <br /> COMPLETE THE FOLLOWING BUSINESS OWNER rNmRmmlom CHEcKrF OWNER CuRREN7z roN FYLE wrrH EHDEj <br /> BUSINESS PHONE: <br /> OWNER'S NAME Ll Onz 0 <br /> First M17 Last <br /> Bu S1 N Ess NAME(if different from Owner N a me) x1D# <br /> 1-,,i1tc111A,r1 A 61' "Ta <br /> OWNER'S HOME ADDRESS f&&o ,v— <br /> CITY 5 rO CA—' 7d Al STATE ZIP3fT---06 <br /> OWNER'S MAILING ADDRESS (if different from Owner's Address) Attention Or Care of <br /> MAILING ADDRESS CITY STATE zip <br /> TYPE OF OWNERSHIP; <br /> CORPORATIONE] INDIVIDUAL PARTNERSHIP[:1 LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY El FED AGENCY El OTHER❑ <br /> FACILITY FILE <br /> FACILITY 10 <br /> :L1 f'AqC04NT 10 <br /> COMPLETE THE FOLLOWING B U S I N ESS FA C I LITY INFORMATION: <br /> Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES El No [I <br /> Is this an E)asTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ❑ <br /> BUSINESS/FAciLrrY NAME(This will be the 8umNA21VAmFon the HEALTH PERMIT) <br /> 7 <br /> A <br /> FACILITY ADDRESS 1IAl1 f FA aL r r Y i s ac a rL E FwD UNI r o r Fpco 142.Al '�Wse the COMMISSARY ADDREW BUSINESS PHONE <br /> . J�fo I <br /> Al <br /> 7 4Q te V <br /> SbeetNumber Direftua Street Name Strwt TV00 suite <br /> CITY(If FACILITY is a MOBILE FOOD UNIT or FOOD VEHICLE US*the COMMISSARY CITY) STATE - zip <br /> C4 <br /> K -7, 21,'�FjT <br /> A <br /> I' d <br /> KEYI � �Y2 <br /> BOARD OF SUPERVISOR DISTRICT Locmiom CODE Aq� 04�W <br /> MAILING ADDRESSfor Health Pemit(ifDiFFERENTfrorn FadlityAddre-'Z5) Attention or Care Of <br /> MAILING ADDRESS CITY STATE zip <br /> SIC <br /> �4 ,APN#: <br /> .2 AX <br /> FACCOUIVTA RESS for fees and charges: OWNER ❑ FAcll-iTyfflus[NESS ❑ <br /> &�ww <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I arriLthe 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 to me at the <br /> address identified above as the ACCOUNT ADDRESS 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 andlor Standards and STATE and/or <br /> FEDERAL.Laws and Regulations. <br /> APPLICANT'S NAME: SIGNATURE: <br /> Please Pffnt <br /> TrTLE: DATE DRIVER'S LICENSE# <br /> (PHOTOCOPY RE2UIRED) <br /> Approved BY Date n ngOM.Proo6esing Complefm <br /> A PROGRAM {EHD 48-02-034 Pink) or WATER SYS-Mm {EHD 46-02-003} form must be completed for each EHD regulated operation at this <br /> LOCATION except UST Program(Use SWRCB farms) <br /> EHD 48-02-035 Masterfile Record-Green <br /> 8/19/08 <br />