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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> �iiiiiiiiiiiil1STERFILE RECORD INFORMATION Fi <br /> SHADED SECTIONS FOR EHD USE ONLY OWNER ID# O CASE# <br /> OWNER FILE <br /> OMPLETETHE FOLLOWINGBUSINESS OWN ERINFORMATION; QfECKIF OWNER CURRENTLYONFILEWITHEHD❑ <br /> BUSINESS PHONE: ..77 [�� <br /> OWNER'S NAME First MI Last S S 4 7r 9 <br /> BUSINESS NAME(If difrerentfrom owner Name) fS+ Soc Sec orTax ID# <br /> fi2/2 r✓ �//� r <br /> OWNERS HOME ADDRESS <br /> CITY 4AP C-/�-F-T STATE ZIP <br /> OWNER'S MAILING ADDRESS (If dirremntfrom Owner's Address) Attention orCare of <br /> MAILING ADDRESS CITY STATE ZIP <br /> TYPE OF OWNERSHIP: <br /> CORPORATION❑ INDMDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITYID#: CO-OWNER ID#: ACCOUNT ID#: OD✓ <br /> E WIrNFORMAUEM <br /> Lslha NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NOan EXIS`ING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ❑ <br /> BUSINESS/FACILITY NAME(This will be th BuST, NAME the HEALTH PERM Ci 0 <br /> IQ <br /> FACILITY ADDRESS(If FACILrrris aJstteFaro UNrror Faro!/Er�rctEuse the rrvnM,ccna...... <br /> ) BUSINESS PHONE <br /> 5-- _ Suite# <br /> CITY(If FACILITY is a MOBI�FOoDUMTFOOD VE sa theCf1MMICCARY CITY/ STAT Zl? <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 l{E7 <br /> MAILING ADDRESS for Health Perm/t(If Dmr-ERENTrrom FadlilyAddress) Attention orCare Of <br /> MAILING ADDRESS CITY STATE ZIP <br /> SIC CODE: APN#: COMMENT: <br /> dr~P'OUNrALWRE.Sf for fees and charges: OWNER ❑ FACILITY/BUSINESS ❑ <br /> RII I INC ANn COMPLIANCF ACKNowi r-nr mFNT: I,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and <br /> I acknowledge that all PERMIT FEES, PEIYALTTES, ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation will be billed to me at the <br /> address identified above as the ACCOUNTnaRFss for this site. 1 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 /> APPLL NYSNAME* IGNATURE• <br /> Please Print <br /> TITLE: /� ,✓ DATE DRIVER'S LICENSE# <br /> Approved By Accounting Office Processing Completed By babe f <br /> A PROGRAM (EHD 48-02-034 Pink) or WATER YSTEM (EHD 46-02-003) form uxu,Ist be completed for eacb EHD regulated operationiexcept UST Program(Use SWRCB forms) <br /> EHD 48-02-035 Masteffile Re <br /> 8119/08 <br />