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h SAN JOAc"IIN COUNTY ENVIRONMENTAL HEALTH PcPARTMENT - STERFILE RECORD INFORMATION Fo-t SHADED SECAONS FOR END USE ONLY OWNER ID# CASE# OWNER FILE COMPLETE THE FOLLOWING USINESS O NFORMATION' t:71ECKIF OWNER CURRENTLYONFILEWITHEHD❑ BUSINESS HONE' OWNERS NAME First NII Last Sz �00 BUSINESS NAME(if diflemotfrom owner Name) � / I , Soc Sec orTax ID# Z o/-\/ I/ter// N /; OWNER'S HOME ADDRESS Z'f / � (/ I2 -� 7 I � � "`�/Z CITY �U �— f� �+ STATE ZIP OWNER'S MAILING ADDRESS (if ditferentfram owner's Address) Attention orCane of MAILING ADDRESS CITY STATE ZIP TYPE OF OWNERSHIP: CORPORATION❑ INDMDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ FACILITY FILE 1=AGILITY ID Q CO-OWNER ID#: ACCOUNT IO#: PL&C FOLLOW"N Is this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO ❑ IS this an EXISTING Business LOCATION but a NEw TYPE Of regulated Business? YES ❑ NO ❑ F BUSINESS/FACILITY NAME(This will be the fusnvE5wjVAmEon a HEALTH PERM y� FACILITY ADDRESS(If FAatrrris a MM EFWD UwTor ta--use th ) BUSINESS PHONE i �. �^T�T 2 i 3 �. 3 SUtte# pzr sz --9�� CITY(if FACILITY IS a MOBILE FOOD Ulvrror F000 VEHicLE use the rnwuissaav Crtrl STrw ZIP Z,1NlJ/-�/ /�/ BOARD DF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 d MAILING ADDRESS for Heall*.fi Permlt(If DIFFERENrfrom FadlltyAddrem) Attention orCare Of MAILING ADDRESS CITY STATE ZIP SIC CODE: APN#: COMMENT: A""""1QXr LQaRL C for fees and charges: OWNER ❑ FACILITY/BUSINESS ❑ Rii i 1Nr ANn P_OMPLIANCF ACKNQwi FnrmFNT: 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 andlor HOURLY CHARGES associated with this operation will be billed to me at the address identified above as the AccouNTA0nREss 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 andlor FEDERAL Laws and Regulations. APPLICANT'S NAME: NATURE' Please Print TITLE: DATE DRIVER'S LICENSE# Approved BY 01 Date Accounting Office Processing Completed Bye� I Date 1 I 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 except UST Program(Use SWRCB forms) EHD 48-02-035 Masterfile Record-Green 8119/08