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SAN JOAr%I IIN COUNTY ENVIRONMENTAL HEALTH V=OARTMENT <br /> ', .ASTERFILE RECORD INFORMATION FOt.. <br /> SHADED SECTIONS FOR EHD USE ONLY OWNER ID# AAfJ 7xi 7. 3'� CASE# <br /> OWNER FILE <br /> COMPLETE THEFOLLOWING BUSINESS QWNER INFORMA770N." CHECKIF OWNER CURRENT[YON mE wrm EHD❑ <br /> BUSINESS PHONE: g� <br /> OWNER'S NAME Fist Ml cast 4 Z <br /> BUSINESS NAME(If di/(ererif f mOwner Name)�G Soe Set orTax ID# <br /> / /�ELcS's/ /r✓ C� / <br /> OWNER'S HOME ADDRESS Z/ p / G'I jf,-t6 ST- v/ <br /> K, <br /> le- <br /> CITY n/(/ T C/ ,/r-, STATE zip fL <br /> OWNER'S MAILING ADDRESS (If o'i/Tereotfrorn Owner's Address) Atteritiori orflre of <br /> MAILING ADDRESS CITY STATE LP <br /> TYPE OF OWNERSHIP: <br /> CORPORATION ElINDIVIDUAL PARTNERSHIP❑ LOCAL AGENCY ElCOUNTY AGENCY STATE AGENCY ElFED AGENCY El OTHER❑ <br /> FACILITY FILE <br /> FAciuTI'ID#: r CO.OWNER ID#: ACCOUNT ID#: <br /> COMPLETE rHf FOLLOWING BUSINESS FACILrTY INFORMATION. <br /> IS this a NEW Business LOCATION Of VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO ❑ <br /> IS this an EIOSrING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ NO ❑ <br /> BUSINESS/FACILITY A E(This will be[h BusrNESSNAArEon the HEALTH PERMIT) <br /> b/�i ZO G 6 41- <br /> FACILITY <br /> FACILITY ADDRESS(If FAl is a AklvteFa WTor Fan VBnaeuse the Crwiw„ccscr Arr s) <br /> BUSIN PHONE <br /> 2 Via! 44F. LOr/'S r° is u� <br /> SuiteS2 <br /> CITY(If FAOU Is a MOsILE FOOD UNaor FOOD VEHICLE use the rn •a�uy ¢soyCm) ST ]JP / <br /> /lei J// {FC � 6 <br /> 33 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> MAILING ADDRESS fOr Health PerMit(If DIFFERENT from Fa 110 Addr ) Attention or Care Of <br /> MAILING ADDRESS CITY STATE 91n <br /> SIC CODE: COMMENT: <br /> dr'r'nrrarr A=RE6S for fees and charges: OWNER ❑ FACILITY/BUSINESS ❑ <br /> FILLING.ING AND romp,IANrF Ar.RNovn Fnr,NFNT: 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, 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 AODRFSS 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 andfor <br /> FEDERAL Laws and R@ ulations. <br /> PPLICANT'S AME' SIGNATUREE <br /> Please Pnnt <br /> TITLE: DATE DRIVER'S LICENSE# ,y/n �J <br /> l APP n-d BY Ct v-� Dat° /O/7J� A—nthV Office Processing Completed By Ll X O� <br /> A PROGRAM (EHD 48-02-034 Pink) or WATER SYSTEM {EHD 46-02-003} form rru-A be completed for eacb EHD regulated operation at this <br /> I GreTION except UST Program(Use SWRCB forms) <br /> EHD 48-02-035 Masterfile Record-Green <br /> 8/19/08 <br />