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SAN JOA17 "N COUNTY ENVIRONMENTAL HEALTH D;:Q.,ARTMENT AN9STERFILE RECORD INFORMATION FO= I� CASE# SHADED SECTIONS FOR EHD USE ONLY OWNER ID# �Dp OWNER FILE rMPLETHEFOLtOWINGBUSINESS NFORM.4TION' QECKIF OWNER CVRRENTLY0NFILEwITHEHD❑ 'i PHONE: SS 'S NAME First AN Last S NAME(If ditferentfirom owner Name) ; SOC Sec or7ax ID# R'S HOME ADDRESS P.1 &M6 t STATE ZIP OWNER'S MAILING ADDRESS (If atrerent from owners Address) Attention orCare of MAILING ADDRESS CITY $TATE ZIP 1 TYPE OF OWNERSHIP: CORPORATION ElINDMDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY El OTHER❑ FACILITY FILE I FACILITY ID#: CO-OWNER ID#: ACCOUNT ID#: i L Is this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO ❑ Is this an ExImNG Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ❑ BUSINESS/FA NAME( Is will the 5twN-g9NANEo n the NEAERIN) FACILITY ADDRESS(If Fi1ClL1TVi5 3MCRHFF�r1"r^'�""""n""L""^"^'r"""'""`"o"�'-'��G}�.�-• Q Q BUSINE�jSS PHONE CITY(If FaGury i MOMLE®D UNrror Faun VEMC[F use the Qtaeniccnev Cm) STATE ZIP? /�-573r / IIIII r/ . /�7 6•DyC` M BOARD OF SUPERVISOR DISTRICT LOCATION CODE tCEY 1 KEY2 ST M EADDRESS for Health Permit(If DiFFERENTfronn FadlityAddress) Attention orCare Of DDRESS CITY STATE ZIP APN#: c"q U,0 ` COMMENT: I CCOVu ZADDREcc_for fees and charges: OWNER ❑ FACILITY/BUSINESS ❑ F Rri r INC,AND COMPLEANCF Ar'KNnw FOGMENT: 1,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 AccOUNI An 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. PPLI NT's AME' I NATURE' Please Print I TITLE: DATE DRIVER'S LICENSE# 1 r.7 . I I iz] Approved By Date /� f F' =A=unting Office Processing Completed By Date A PROGRAM (EHD 48-02-434 Pink} or WATER SYSTEM {EHD 46-02-003} form must be completed for each EHD regulated operation at this t! I O A13ON except UST Program(Use SWRCB forms) ? EHD 48-02-035Masterfile Record-Green 8/19/96 =