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SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH r-OARTMENT ,STERFILE RECORD INFORMATION FO., SHADED SECTIONS FOR EHD USE ONLY OWNER ID# ODBDD CASE# OWNER FILE COMPLETE THE FOLLOWING USINESS NFORMA770N' CyFECKIF OWNER CURRENTIYON Free wrrT/EHD❑ BUSINESS 77 PHONE: OWNER'S NAME Fist MI Last BUSINESS NAME(If dl/rerent From Owner Name) Soc Sec OrTax ID# OWNER'S HOME ADDRESS 2 r /�I/u roL��✓ CITY �-o STATE OWNERS MAILING ADDRESS(If oftnaut From Owner's Address) Attention or Care of MAILING ADDRESS CITY STATE ZIP TYPE OF OWNERSHIP: CORPORATION❑ INDIVIDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ NATE AGENCY❑ FED AGENCY❑ OTHER❑ FACILITY FILEq— FACILITY ID CO-OWNER ID M ACCOUNT ID#: F IS this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO ❑ Is this a0 EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ NO ❑ BUSINESS/FACILITY NAME(TNs will be the usrHEssANNFon HEALTH PERMIT) T` O FACILITY ADDRESS(UFAis a MbawFantAuror Fan WOOLFuse th ) BUSINESS PHONE 54G Suites CITY(If FACILRYIs a�llOWLE FOOD UN/Tor FOOD VEHICLE use the comm csa=v rm) STB,TE� zip�� / r/'� O h / L//ri(Vt 2- `/-/1 BOARD OF SUPERVISOR DISTRICT LOCATION CODEKEY1 KEY2 MAILING ADDRESS fol Health Penhhhh�If DIFFEROVTfrom FadtttyAoore ) Attention"Cam Of MAILING ADDRESS CITY STATE LP SIC CODE: APN#: COMMI ACC=WT 442DR SS for fees and charges: OWNER ❑ FACILITY/BUSINESS ❑ Rn I wa ANn CnMpi IANrF ArRNow,Fnr.MFNT; I,the undersigned Applicant,certify that I am the Owner, Operator,or Authorized Agent of this Business,and I acknowledge that all PERMIT FEES, PENALTIES, ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation will be billed t0 me at the address identified above as the ArroUNTADoaeSS for this site. I also certify that all information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or FEDERAL Laws and Regulations. ....... 5 AMEIGNATURE' Please Pant TITLE' DATE DRIVERS LICENSE If Approved By C r Date A4 rdting Office Processing Completed By Date ®. A PROGRAM {EHD 48-02-034 Pink} or WATER SYSTEM {EHD 46-02-003} form must be completed for each EHD regulated operation at this I n rATrnN except UST Program(Use SWRCS forms) EHD 48-02-035 Masterfile Record Green 8/19/08