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SAN JOA 'q COUNTY ENVIRONMENTAL HEALTH *ARTMENT VAO'STERFILE RECORD INFORMATION FOM SWEDSECTIONSFOREHD USE ONLY OWNER ID# I CASE# i I! OWNER FILE COMPLETETHEFOLLOMNGBUSINESSOWNERINFORMATION: I� CHECK IF OWNER CURRENTLYONFILE mTNEHD + II BUSINESS -- f PHONE OWNER NAME First Mt 1� Last i BUSINESS NAME(If different from Owner Name) so' See or Tax ID# GrTY of 7iAo-Afi r t I ` OWNER HOME ADDRESS 15 d 1-/ L'V f r CITY /y7 r'- I� C/A STATE ZIP !O OWNER MAILING ADDRESS (If different from Owner Address) Attention or Care of MAILING ADDRESS CITY STATE ZI i TYPE OF OWNERSHIP: II I CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY COUNTY AGENCY ElSTATE AGENCY El FEDI AGENCY❑ OTHER❑ II � F FACILI'T'Y FILE + FACILITY ID#: ®Q CO-OWNER ID#: J. ACCOUNT ID#: 9 f COMPLETE THE FOLLOWING BUSINESS FACILITY lwoRMATION: IS this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO I Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES W NO ❑ BUSINESS�� 1^'� (This will t��rNr=SSNanteo�the HEALTH PERM FACILITY ADD DRESS(If FACILITY Is a MMLE Foca UHrror Foo VEHICLE US a it 14 f. r ` &r Bt�SINE55 PHONE Street N�jmbef� N �I Suite# I. i CITY(If FACrurYI5_a M4oal�n UNIT or Food VEHICLE use the CnnnMs�Aar Cmr1 CA STATE ZIII BOARD OF SU7P/ERRVVISOR DISTRICT LOCATION CODE I KEY1 KEY2 p MAILING ADDRESS for Health Permit(If DIFFERENT from Facility Address) III Attention or Care Of k MAILING ADDRESS CITY STATE Zip I� SIC CODE: APN#: COn+�nrr: L!r_rn1fur AnnRpSs for fees and charges: OWNER ❑ FACILITY/BUSINESS i❑ I, the undersigned Applicant, certify that I am the Owner, Operator, or Authorized Agent of this Business, and I acknowledge that all PER11iq FEES,PENAr Tws,EN.FoxcEmENT CHARGES and/or HouRLY CHARGES associated iwith this operation will be billed tome at the address identified above as the Accorwr.ApnitEss for this site. I also certify that all information provided on this application is true and i correct; and that all regulated activities will be performed in accordance 14th all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or FEDERAL Laws and Re ulations. APPLICANT NAME: II SIGNATURE: Please Print TITLE: DATE I DRIVER'S LICENSE# (EtjoTOCOpy REQUIRED I i i + Approved By Date Z. Q Accounting Office Processing Completed By Date ` I � A PROGRAM{EHD 4"2-034 Pink}or WATER SYSTEM{EHD 46-02-003)form R]Ihst be completed for each EHD regulated operation at this except UST Program(Use SWRCB forms) EHD 48-02-035 Masterfile Record-Green 10/9/2003 =-