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M SAN JOA("'-(IN COUNTY ENVIRONMENTAL HEALTH P=PARTMENT <br />' ASTERFILE RECORD INFORMATION F <br /> l SHADED SECTIONS FOR EHD USE ONLY OWNER ID# CASE# <br /> 1 OWNER FILE <br /> OMPLETE THE FOILOWINGIMMOWNERNFORMATION' CHECKrFOWNER CZIRRENTLrDArFILE WrrHEHD❑ <br /> BUSINESS P '1 - 2, 2,00 2j y <br /> OWNER'S NAME ry; / L�D <br /> F�Sr rur Lost <br /> BUSINESS NAME(If difYermtfr.m Owner ame) Soc Sec crTax IA# <br /> T-Y 0'F <br /> OWNER'S HOME ADDRESS d jVAj f CCEN A, D&= <br /> 7 <br />` CITY STATE ZIP .S3 36 <br /> I OWNERS MAILING ADDRESS (If difrerentfromOwner's Address) Attention orCare of <br /> MAILING ADDRESS CITY STATE Zip <br /> I <br /> TYPE OF OWNERSHIP: <br /> CORPORATION❑ INOMDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> j FACILITY ID#: 12f CO-OWNER ID#: ACCOUNT HI#:O p2 <br />!� COMPLEZE ME EO 4 Q WING <br /> t Is this a New Business LOCATION or VEHICLE not:previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENY21 YES ❑ NO ❑ <br /> o Is this an ExIsTING Business LOCATION but a New TYPE of regulated Business? YES ❑ No ❑ <br /> BUSINESS/FACILITY NAME(This will be the&wwExsMAmon the HEALTH PERMIT) Ufz- <br /> ^�� <br /> LA <br /> FACILITY ADDRESS(If FAaLrrris a Miwt,'FC00 UNrror Fr VkHraEuse the rnmmi,;cArzv AnnaFcc) 9 `(� BUSINESS PHONE <br /> yoz0 , ST <br /> suite# <br /> CITY(If FA.Lrrns a MOBUE Foo.UNrror FOOD VEHICLE use the Camaguey C STAT ZIP <br /> BOARD OF SUPERVISOR DLSTRICT LOCATION CODE KEY1 KEY2 <br /> MAILING ADDRESS for Health Permit(If DIFFERE'NTfronn FaUlityAddress) Attention orCare Of <br /> MAILING ADDRESS CITY STATE ZIP <br /> SIC CODE: APIN#: CONMENi': <br /> 4C4= frADD ff f for fees and charges: OWNER ❑ FACILITY/BUSINESS ❑ <br /> r <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the 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 /> k <br /> address identified above as the ArroUNT AMORFSS 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 /> I FEDERAL Laws and Regulations. <br /> APPLICANT'S NAMEG SIGNATUREE <br /> Please Print <br /> TITLE: DATE DRIVER'S LICENSE# <br /> (PHOTOCOPY REQUIRED) <br /> Approved By Date Ac=ndng Office Processing Completed By Date y <br /> A PROGRAM {EHD 48-02-034 Pink} or WATER SYSTEM {EHD 46-02-003} form t73ltSt be completed for each EHD regulated operation at this <br /> t nrerrnN except UST Program(Use SWRCS forms) <br /> EHD 48-02-035 Masterfile Record-Green <br /> 8/19/08 <br />