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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DFOARTMENT <br /> A <br /> tl.�TERFILE RECORD INFORMATION FOF,..4 II <br /> SHADED SEcnoms FoR EHD UsE ONL Y .01" <br /> CASE <br /> OWNER FILE <br /> COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION: CHecKrF OWNER CuRR&vnyoN,FrLEWITH EHD❑ <br /> BUSINESS PHONE: <br /> OWNER'S NAME <br /> First my <br /> Last <br /> BUSINESS NAME(if different from Owner Name) SOC Sec orTax ID# <br /> OWNER'S HOME ADDRESS <br /> CITY C.5C,A LU' I'V LZIP <br /> OWNER'S MAILING ADDRESS (If different from Owner's Address) Attention orCare of <br /> S-_ leAR)f 12V <br /> MAILING ADDRESS CITY <br /> . 'r'T vc or/ <br /> TYPE OF OWNERSHIP: <br /> CORPORATION El INDIVIDUAL PARTNERSHIP El LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY El FED AGENCY E] OTHER El <br /> FACILITY FILE <br /> co-OWNER 16# <br /> K 17A g$��T <br /> COMPLETE THE FOLL 0 WZNG B U S I IN E S S FACILITY INFORMATION: <br /> IS this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES El No :, <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES El No El <br /> BUSINESS/FAcILMjTNE(This will be the HuswEssNAmEon the HEALTH PERMIT) <br /> /i <br /> FACILITY ADDRESS(If FAFmj a MrLEFCOD UmTor F00 PaCLEuse fbef:OMMISSARY ACORESS) BUSINESS PHONE <br /> — 1Z 11 <br /> &Y—tNumber D""t"' Street Name 517-66t T;,.w Suite 4 <br /> CITY(if FAaury is a Moq&E FOOD UNfTor Fdoo VEHrcLE use the CommissAgy CITY) ST zip <br /> zip <br /> M�0 <br /> 65-C,A <br /> ry 447 <br /> BOARD 0FSuPERvxsoRDIsmcr K A� <br /> K EY1 A <br /> MAILING ADDRESS for Health Permitaf DiFfERENTfrorn Facifity/lold—) Attention orcare Of <br /> MAILING ADDRESS CITY STATE ZIP <br /> r6m7-Ws -- 'Y <br /> 1rF_WV <br /> T <br /> ON J <br /> SICCoDE:A <br /> �!E <br /> —APN#' <br /> ACCOMEA—for fees and charges: OWNER FAciLiTylBUSINESS <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 /> 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 and/or Standards an'd STATE and/or <br /> FEDERAL Lawsand Regulations. <br /> If <br /> APPLICANT'S NAME: SIGNATURE: <br /> Trn-E: please PrintDATE DRIVER'S LICENSE# <br /> (PHOTOCOPY REQUIRED) <br /> ting- ce Processing 6�pii6ii� W7 <br /> LA�proved By Accij�' OM <br /> A� <br /> Date <br /> A PROGRAM -CEHD 48-02-034 Pink) or WATER SYSTEM (EHID 46-02-003). form must be completed for each EHD regulated operation at this <br /> LOCATION except UST Program(Use SWRCB forms) I <br /> FHD 48-02-035 Masterfile Record-Green <br /> 8119/08 <br />