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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT YATERFILE RECORD INFORMATION FD SHADED SECnONS FOREHD USE ONLYOWNER ID# s-C.c CASE A i 77:1 OWNER FILE COMPLETE THE FOLLOWING USINESS NFORMA770tV' CNECR IF OWN ER CURRENrz r ON FILE Wmr EH D❑ BUSINESS HONE r7 OWNER'S NAME Fvst Afl Lest BUsINEss NAME(If omf thomowner Name) Soc Sec orTax ID# / z r/ /A45 SJ //✓ Cl OWNER'S HOME ADDRESS L CITY STATE ZIP OWNER'S MAILING ADDRESS (If different from Owners Address) Attention orCam of MAILING ADDRESS CITY STATE ZIP TYPE OF OWNERSHIP: CORPORATION❑ TNOWIDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ FACILITY FILE #: TCO-OWNER ID#: ACCOUNT ID#: Q FACILITY ID D P IS this a NEW Business LDCATION Or VEHICLE not preVIOUSIY 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 is will tie the BusnmsslllEon the HEALTH PER ,,i r c o//i r- 6;!5-I/1 GL,S FACILITY ADDRESS(If Fico rrris a mard,FttntftTm Fox 4&n¢Euse the Crwmrccevv Annvccc) �� r . ,I,An,�vrsA �, �z" sz��od Suite# CITY(if FACILITY Is a MOBILE FOOD UND'of FOOD VENICLEUM the r'nMuitsd rCrtv) STAGE^ -7fP CQ�j/ z BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 MAILING ADDRESS for Health Permit(if OIFFERENTfrom FddlityAddress) Attention orCare Of MAILING ADDRESS CITY STATE zip SIC CODE: APN#: COMMEM; Arrf)IUVT dAnaFcc for fees and charges: OWNER ❑ FACILITY/BUSINESS ❑ RILL i NC AND COMPI IANC E AC RND• F nMFNr; ],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 tome at the address identified above as the ACCOUNT AOORFcc 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. PPLICANT'S AMEI NATURE' Please Pnnt TITLE. DATE DRIVER'S LICENSE# Approved By�. Date // /� Q Accounting Ocoee Processing Completed By Date 17'9-. / A PROGRAM (EH 46-02-034 Pink} or WATER SYSTEM (EHD 46-02-003) form must be completed for each EMD regulated operation at this I OCATION except UST Program(Use SW RCB forms) EHD 48-02-035 Masterfile Record{Green 8/19/08