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SAN JOAPI IN COUNTY ENVIRONMENTAL HEALTH DFOARTMENT <br /> 1 STERFILE RECORD INFORMATION Fr <br /> SHADED SEC77ONS FOR EHD USE ONLY OWNER ID# �� CASE# <br /> 1 7= <br /> OWNER FILE <br /> OMPLETETHE FOLLOWING BUSINESS OWNERNFORMATTOW OmgLcrFOWNERCuRAENr[YONFrLFwrrHEHD❑ <br /> BUSINESSPHONE' _ z O <br /> OWNER'S NAME First M1 Lastq41/ <br /> i BUSINESS NAME(If differentfiom owner Name) Soc Sec orTax ID# <br /> o G <br /> OWNER'S HOME ADDRESS 3,90 T6,r41,A1 <br /> CITY d STATE ZIP <br /> OWNER'S MAILING ADDRESS (If dill wntfmm Owner's Address) Attention orCare of <br /> MAILING ADDRESS CITY STATE ZIP <br /> TYPE OF OWNERSHIP: <br /> CORPORATION❑ INDIVIDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID#: CO-OWNER ID#: ACCOUNT ID#: �Q <br /> /y F N' <br /> IS this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO ❑ <br /> h <br /> Is this an ExISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ❑ <br /> BUSINEss/FACILITY AME(This will be the BUSINEssNnMEon the HEALTH PERM 2— <br /> al b aST�� v/� 74 <br /> FACILITY ADDRESS <br /> (If FAQIITYis a }'xE FOOD OD IAEjiaE�use the rn,+ml—gv Ar—E <br /> .`"L. � BUSINESS PHONE <br /> a 01) v L suite ft <br />} CITY(If FACrury is a MOBILE FOOD UNrror FOOD VEMCLE use the ra mwccaQv Crrv) STAT ZIP <br /> I <br /> =KEY1 KEY2 <br /> M BOARD OF SUPERVISOR DISTRICT LOCATION CODE <br /> MAILING ADDRESS for Health Perm►t(if DIFFERENTfronn FacllityAddress) Attention orCare Of <br /> k MAILING ADDRESS CITY STATE ZIP <br /> I SIC CODE: APN#: COMMENT: <br /> k <br />! err-n■■nrr dnnnFce <br /> for fees and charges: OWNER ❑ FACILITY/BUSINESS ❑ <br /> RII I INC ANn COMPLIANCE ACKNOwr Pnrmr NT: I,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and <br /> E 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.4ccoUNTAWRESS 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 and/or Standards and STATE andlor <br /> FEDERAL Laws and Regulations. <br /> APPLICANT'APPLICANt§NAMEv IGNATUREm <br /> F Pifase Print <br /> TITLE: �7 DATE DRIVER's LICENSE# <br /> ! Approved By /7 ,{ Date �)� Aacaunting Omce Processing Completed By Date ryB ,p <br /> A PROGRAM {EHD 48-02-034 Pink) or WATER SYSTEM {EHD 46-02-003} form Dvict be Completed for each EHD regulate operation at this <br /> 'r <br /> I OCATTON except UST Program(Use SWRCS forms) <br /> EHD 48-02-035 Masterfile Reoord-Green <br /> r 8/19/1/8 <br />