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SANJOA COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> .STERFILE RECORD INFORMATION Fc, <br /> ..d <br /> OWNER ID# "� CASE# <br /> OWNER FILE <br /> COMPLETETHE FOLLOWINGBUSINESS OWN ER INFORMATION: CHECKIF OWNER CURRENTLYONFILEw1rHEHD <br /> 13 <br /> BUSINESS PHONE O <br /> OWNER NAME First M/ Last Z 9 <br /> o <br /> BUSINESS NAME.(If different fromowner Name) Soc Sec orTax ID# <br /> C17- A/ TA5 L B <br /> OWNER HOME ADDRESS Z061 Ul C,/- rV_r, ! T <br /> CITY �� STATE ZIP Ity3 <br /> OWNER MAILING ADDRESS (If different from Owner Address) Attention orCare of <br /> I <br /> MAILING ADDRESS CITY STATE ZIP <br />{ TYPE OF OWNERSHIP: <br /> CORPORATION ElINDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY ElCOUNTY AGENCY ElSTATE AGENCY ElFED AGENCY OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID#: CO-OWNER ID#: ACCOUNT ID#: <br /> COMPLETE THEFOLLOWING BUSINESS FACILIIY INFORMATION.' <br /> Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES ❑ NO ❑ <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ NO ❑ <br /> f <br /> I BUSINESS/FACILITY NAME{This will be the 6usrNEssN,amEon the HEAL H PERM <br /> Z <br /> FACILITY ADDRESS(If F+crurris/a�MOBILE FOOD UUNrror FOOD VEHeaLEuse the r nMMicsaQY AoorxEss} BUSINESS PHONE <br /> Suite# <br /> CITY(if FACILrrYISaMOBILE FOODUNITorFoodVEH)CLEuse the Cammac_ARv_-rrrv) ST/ITiEM Z1PEy�y <br /> k 7-r r-,A <br /> I BOARD OF SUPERVISOR DISTRICT LOCATION CODE 7 KEY1 KEY2 <br /> MAILING ADDRESS for Health Permlt(If DIFFERENTfrom FaciityAddress) Attention or Care Of <br /> 4 MAILING ADDRESS CITY STATE ZIP <br /> SIC CODE: APN aY: COMMENT: <br /> dr`=fiVrdQDRESS for fees and charges: OWNER ❑ FACILITY/BUSINESS ❑ <br /> I, the undersigned Applicant, certify that I am the Owner, Operator, or Authorized Agent of this <br /> I Business, and I acknowledge that all PERMIT FEES,PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation will be <br /> billed to me at the address identified above as the AccoUATADDSEss for this site. I also certify that all information provided on this application is true and <br /> correct; and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards <br /> and STATE and/or FEDERAL Laws and Re alations. <br /> APPLICANT NAME: SIGNATURE: <br /> Please Print <br /> TITLE: DATE DRIVER'S LICENSE# <br /> (PHOTOCOPY REG <br /> Approved By C, 1 Dais Accounting Office Processing Completed By Date a <br /> 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 LOCATION <br /> except UST Program(Use SWRCB forms) <br /> EHD 48-02-035 Masterfile Record-Green <br /> 10!9!2003 <br /> y` 4 <br />