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SAN JOA 'N COUNTY ENVIRONMENTAL HEALTH r .RTMENT MASTERFILE RECORD INFORMATION FORtd' SHADED SECTIONS FOR EHD USE ONLY II OWNER ID# yl n B S/7 Y CASE# OWNER FILE COMPLETE THE FOLLOWING USINE NFORMATION' QYECRrF OWNER CURREN71 r ON FILE WrTH EHD❑ BUSINESS HONE' 77 6 '9 OWNER'S NAME FTSI MI Last �L�` L BUSINESS NAME(if di?LYenthom Owner Name) E SOC Sec orTax ID JISI�l-Z arOS ,7"✓�i 4 & /A/C� / OWNER'S HOME ADDRESS /''"f/T' LcL DIL Z S)- f'l.R CITY t vT lE - .A STATE ZIP �p OWNER'S MAILING ADDRESS (if dlffv nt from Owner's Address) Attemion orCare of MAILING ADDRESS CITY STATE ZIP TYPE OF OWNERSHIP: CORPORATION❑ INDIVIDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ FACILITY FILE FACILITY ID#: CO-OWNER ID#: ACCOUNT ID#: Q COMPuTz,rHE FOLL12WrNG BUSINESS FACILrrY rNFORMATrOW Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO ❑ Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ❑ BUSINESS/FACILITY NA�+E(This will be the BusrNEsslWNeon Ne EALTH PERMIT) q - !n/ 'v C I L- 4TiY8i 0/a FACILITY ADDRESS(If FAemis a PVs fon tMorror RXo VetiaElli ADDeEssI BUS PHONE 12, -144 � i see# `z� Sze- 6Db CITY(If FACrury is a MOBILE FOOD UNr oO VEHICLE use the rD--cs ov rrv) ST LP�, d BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 MAILING ADDRESS for Health Permit Ir O/FFERENTrronl Fadlity Address) Attention Or Care ON MAILING ADDRESS CITY STATE ZIP SIC CODE: APN#: COMMENT: dr�nrnilr An 21 for fees and Charges: OWNER ❑ FACILITY/BUSINESS ❑ RIP I INr.A•n COMy I P ACKNOWLFninlii : 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 to me at the address identified above as the Ac O rAr�y r�OOR�cc 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. APPLICANT'SAM SIGNATURE' Flaw Rin' TITLE: DATE DRIVER'S LICENSE# Approved BY - Data /r Ac nting 01 Processing Completed By D Dah A PROGRAM (EHD 48-02-034 Pink) or WATER SYSTEM {EHD 46-02-003} form mu.Y be completed for each EHD regulated operation at HAf I OC'ATION except UST Program(Use SWRCB forms) EHD 48-02 035 Masterfle Record Green 8/19/08