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SAN JOA N COUNTY ENVIRONMENTAL HEALTH ^-OARTMENT <br /> -MASTERFILE RECORD INFORMATION FG" <br /> SHADED SECWNSPDREHD USE ONLY OWNER ID# D� G�, ?/ CASE# <br /> OWNER FILE <br /> OMPLE7E THEFOLLOWING BUSINESS 0 NER&MRNATION• CHECKIF OWNER CURRENTIYONFILEWITHEHD❑ <br /> BUSINESS PHONE* <br /> OWNER'S NAME Fvst MI Last <br /> BUSINESS NAME(If di/ferentfmMOwner Name) Soe Sec DrTax ID At <br /> OWNER'S HOME ADDRESS Wi)/�E eV 14 PL, <br /> Cm 0 STATE ZIP s 30 <br /> OWNER'S MAILING ADDRESS (If different from Owner's Address) Attention of Care of <br /> MAILING ADDRESS CITY STATE ZIP <br /> TYPE OF OWNERSHIP: <br /> CORPORATION❑ INDIVIDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ NATE AGENCY❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID#:D <br /> CO-OWNER ID#: ACCOUNT ID#: O <br /> COMPLEm F L <br /> Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENYT YES ❑ NO ❑ <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ❑ <br /> BUSINESS/FACILITY NAME(This will be the BuszNE NANEon the HEALTH Fl <br /> G s <br /> FACILITY ADDRESS(If FAm is a M1XNIafaY>UN/. or fab Vonaeuse therrxv "-'Ar Igg) BUSINESS PHONE <br /> rude# <br /> CITY(II Fa �ATLE.Foq ONrtor FOOD VEHnLE use the COMMISSARY Crtv) tAftention <br /> TATE ZIP <br /> BOARD OF SUPERVLSOIRN /DISTRIV�R LOCATION CODE KEY1 KEY2 <br /> MAILING ADDRESS for Health Permituf DIFFERENTrrom Facility Add2 ) orCare O/MAILINGADDRESS CITY TATE ZIP <br /> SIC CODE: APN#: O COMMENT: <br /> Al00IIET AWRESS for fees and charges: OWNER ❑ FACILITY/BUSINESS ❑ <br /> Flit oar.AND rnmPLIANCF ACKNOWI FDGMENT: 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 andfor HOURLY CHARGES associated with this operation will be billed to me at the <br /> address identified above as the A� Q wir�S TAnDREcc 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 and/or Standards and STATE and/or <br /> FEDERAL Laws and Re ulations. <br /> APPLICANT'S AME' I NA RE' <br /> Please Pant <br /> TITLE: DATE DRNER'S LICENSE# <br /> Appnived aYWts (�6 v Accounting ORka Procesclrq Completed eY Data <br /> A PROGRAM {EHD 48-02-034 Pink} or WATER SYSTEM {EMD 46-02-0031 form must be completed for each EHD regulated operation at this <br /> I rlrATTON except UST Program(Use SWRCB forms) <br /> EHD 48-02-035 Masterfile Record{Green <br /> 8/19/08 <br />