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SAN JOA IIN COUNTY ENVIRONMENTAL HEALTH r-DARTMENT 1mASTERFILE RECORD INFORMATION Fc. .'. SHADED SECTIONS FOR EHD USE ONLY OWNER ID# B©$?3 Lj CASE# OWNER FILE OMPLETE THE FOLLOWING B U S I N ESS OWN E R INFORMA TION' CHECK TF OWN ER CURRENn Y ON FILE wmr EH D❑ BUSINESS HONE: /� D OWNER'S NAME ,Ut Last BUSINESS NAME(If dlYferenthom Owns Name) Soc Sec OrTaX ID# �� SS /�/✓ G OWNER'S HOME ADDRESS Z 7 8' ,� M/TG1115 -l- DO l�- Cm r L (�A STATE MP OWNER'S MAILING ADDRESS (If d/ffemnt from Owner's Address) Attention or Care of MAILING ADDRESS CITY STATE ZIP TYPE OF OWNERSHIP: CORPORATION❑ INDIVIDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ DTNER❑ FACILITY FILE FACILITY ID#: Tq/ CO-OWNER ID#: ACCOUNT ID M IS this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO ❑ Is this an DUSTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ NO ❑ BUSINESS/FACILITY 2AME(This will be the NAFrEon[he H,FALTH PERMIT) 1F Zv /2 r - />7�42 T� FACILITY ADDRESS(If FAaLm-is a filaWfWvWTorFran VBr use the rr ,,;Y ArrnE�<) BUSIN PHONE zS S - Ari 9-ZJ 5-Z�-/ern Suite It CITY(If FACturYis a MOBILE FOOD UNIT or FOOD VEHICLE use the rnuuassARY G, STATE LP 5' / C, ck-T v I ox BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY/ KEY2 MAILING ADDRESS for Health Permft(If DIFFERENTfrom FanlityAddms) Attention or Care Of MAILING ADDRESS CITY STATE ZIP SIC Cooe: Ong APN;k; 17jAEZO COMMENT: di-i-fw rr ADDRESc for fees and charges: OWNER ❑ FACILITY/BUSINESS ❑ Ru,,Na ANn rnmpi iANCF AcKNowi onrmFNT: 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 tome at the 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 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'S AME' SIGNATURE' Please Print TITLE: �) DATE DRIVER'S LICENSE At Approved By ,+ � �e/D �d Acmuntln9 Dmra Processing Completed By Data A PROGRAM (EHD 48-02-034 Pink} or WATER SYSTEM (EHD 46-02-003) form must be completed for each EHD regulated operation at thi l GrATION except UST Program(Use SWRCB forms) EHD 48-02-035 Masterfile Record Grr 8/19/08