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SAN JOP-_'IN COUNTY ENVIRONMENTAL HEALTH --PARTMENT ivIASTERFILE RECORD INFORMATION Foimro SHADED SECRONS FOR EHD USE ONLY OWNER ID# 0,,9Z ag'_70 :=CASE# OWNER FILE COMPLETE THE FOLLOWING BUSINESS OWNERINFORMATION: CHECKIF OWNER CURRENTLY ON FILE MTHEHD BUSINESS PHONE OWNER NAME �312_ 9 3 -7First MI Last BUSINESS NAME(If different from Owner Name) SOC Sec or Tax ID# C / ,- Y op sTo c%To A/ OWNER HOME ADDRESS 'L5 p p 14A V CITY6r/ STATE ZIP 5 Zi Q3 OWNER MAILING ADDRESS (If different from Owner Address) Attention or Care of MAILING ADDRESS CITY STATE ZIP TYPE OF OWNERSHIP: CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP El LOCAL AGENCY ' COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER El FACILITY FILE FACILITY ID#: CO-OWNER ID#: ACCOUNT ID#: COMPLETE THE FOLLOWING BUSINESS FACILITY INFORMATION: 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 NAME(This wjh be the BUSINESS NAmEon the HEALTH PERMI,T,2 Llzv /c L- c 0 SA/,,l>AX-Y STn PP FACILI7YADDRESS(IfFaclurY saMosaEF000UNtrorFooDVErucLEuseth� G�� ) BUSINESS PHONE t�7 77 D1C�//rrG)' C O v,6 A T M"V�. ��— Suite# Street Number Direction Street Name Street CITY(If FActurYls a MOBILE FOOD UNIT or FOOD VEHICLE use the CoMMissaRv Cm) STATE ZIP BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEYI KEY2 MAILING ADDRESS for Health Permit(if DIFFERENT from FacitityAddress) Attention or Care Of MAILING ADDRESS CITY STATE ZIP SIC CODE: APN#: COMMENT: AC`C`nfINT AnnRFSS for fees and charges: OWNER ❑ FACILITY/BUSINESS ❑ Bi r 1Nc, AND Comp TANCF, ACKNOWr.FDGMF,NT: I, the undersigned Applicant, certify that I am the Owner, Operator, or Authorized Agent of this Business, and I acknowledge that all PERM{IFEES,PENALT/ES,ENFORCEAfENT CHARGES and/or HOURLY CHARGES associated with this operation will be billed to me at the address identified above as the ACCOUNTADDRFcs 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 FFDERAI.Laws and Reputations. APPLICANT NAME: SIGNATURE: Please Print TITLE: DATE DRIVER'S LICENSE# Approved By �. Date Accounting Office Processing Completed By Date qz 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 OrATION except UST Program(Use SWRCB forms) EHD 48-02-035 Masterfile Record-Green 10/9/2003