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SAN.jOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT i STERFILE RECORD INFORMATION Fc j SHADED SECRDNS FDR EHD(ISE ONLY OWNER ID# CASE# 1� �f7 !OWNER FILE J COMPLETE THE FOL LOW/NGBU81NESS OWNER INFORMATION: CHECKiF OWNER CURREAfmrON'FILE wITHEHD❑ BUSINESS um -5- v 1'{vt, PHONE: I. OWNER'S NAME 909 First M1 Last ✓J i ��J BuSINESs NAME(if ddTerent finmOwner Name) Soc Sec,orTax ID# OWNER'S HOME ADDR S Q �7� CITY ZIP / SZZD OWNER'S MAILI G ADDRESS (If diilbrentfromOwners Address) Attentlan arCare of MAILING ADDRESS CITY —FiTATE7 ZIP TYPE Of OWNERSHIP: CORPORATION❑ INDIVIDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY . OTHER❑ FACILITY FILE ' FACILITY ID#:049 CO-OWNER ID#: ACCOUNT ID#: COMPLETE THE FOLLOw/NGBUSI NESS FACILITY INFORMATION.' Is this a NEw Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES NO ❑ RenweTuru�7 Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ NO BUSINESS/FACILITY NAME(This will be the BusnVEss HAaEon the HEALTH PERM ` ` �^ ' 1 V(�I mks FACILITY ADDRESS(If FAciLrrris a MoaxeFaoo UNiror FooD VEHICLEuse the COMMISSARY ADDRESS) BUSINESS PHONE Suite# CITY(If FAcrurvIs a Moshe FooD UNrr or FooD VEHicLE use the COMMISSARY Crryl STATE ZIP BOARD OF SUPERVISOR DISTRICT LOCATION CODE U A& TKEY1 KEY2 MAILING ADDRESS for Health Permit(lf DIFFERENTtorn FaeilityAddress) Attention orCare Of 'I MAILING ADDRESS CITY STATE Zip SIC CODE: APN s:()6 51 '70 COMMENT: J. =CCOUACCOUNTADDRESS for fees and charges: OWNER ❑ FACILiTYIBUSINESS ❑ BILLING AND COMPLIANCE ACKNOWLEDGMENT: 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 to me at the address identified above as the ACCOUNTADDRESS 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. 'I APPLICANT'S NAME: SIGNATURE: Please Print TITLE: DATE DRIVER'S LICENSE# 'I PHOTOCOPY REQUIRED Approved ay Gale Accounting Office Prxeesing Completed By Dela n A PROGRAM-{EHD 48-02-034 Pink}or WATER SYSTEM{EHD 464L m rrruabbe completed for each EHD regulated operation at this LOCATIOK- except USF Program(Use SWRCB forms) i EHD 48-02-035 Masterfile Record-Green 8119108 I