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I SAN JOAF4IIIN COUNTY ENVIRONMENTAL HEALTH Dr-PARTMENT <br /> �STERFILE RECORD INFORMATION F[ <br /> SHADED SECTIONS FOR r;HDUSE ONLY OWNER ID �� CAsE# <br /> -L.ge <br /> .= <br /> OWNER FILE <br /> F OMPLETETHEFOLLOININGBUSiNESS W NFDRMATION• CWCKrF OWNER CURREIMYON FILE WrrHEHD❑ <br /> BUSINESS <br /> OWNER'S NAME H7ONE• ^� <br /> FrSt M/ Last <br /> BUSINESS NAME If,differenthomownerName) Soc Sec orTax ID# <br /> r e'f 0 <br /> OWNER'S HOME ADDRESS ,� rif C HoG O - <br /> CITY G Is- - s ZI <br /> OWNER'S MAILING ADDRESS (If different fromOwner's Address) Attention orCare of <br /> MAILING ADDRESS CITY STATE ZIP <br /> TYPE OF OWNERSHIP: <br /> CORPORATION❑ INDIVIDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID M CO-OWNER ID#: ACCOUNT ID#: g <br /> NDVFORMAMatz <br /> I$thisa NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES C] No C1Is this an EXEMNG Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ❑ <br /> BUSINESS/FAaLITy NAME is will be the Bu.Mj1E15AU11,Fon the HEA TH PERM45SJITI <br /> r <br /> FACILITY ADDRESS(If FAaurris a LEF2O rumor��r.0--use the <br /> � �CCM USINE PHONE <br /> Suite# <br /> CITY(If FAciLrryis a moBiLE FooD uNrT r FOOD VEN&E uSe the roMmR.RARY(9rr) $TATE ZIP <br /> Z DOD J ,S2 v <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 �KE <br /> MAILING ADDRESS for Health Perm/t(If DIFFERENTfrom FacilrryAddrnu) Attention orCareOf <br /> MAILING ADDRESS CITY STATE ZIP <br /> 51C Cone: APN#: COMMENT; <br /> =A=UM1 ADDRESS for fees and charges: OWNER ❑ FACILITY/BUSINESS ❑ <br /> BILLING ANO C6MPLEANr-F Ar-KNowLEDamFNT: 1,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and <br /> I acknowledge that all PERMIT FEES, PENALTIES, ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation will be billed to me at the <br /> address identified above as the ACCouNrAanaess for this site. I also certify that all information provided on this application is true and correct;and that <br /> all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or <br /> FEDERAL Laws and Re ulations. <br /> P N 5 NAMED STGNA RE' <br /> Please Pfiat <br /> TITLE: DATE DRIVER'S LICENSE# <br /> Approved By Date ® '� Accounting Office Processing Completed By Date !r jt1qL <br /> A PROGRAM {EHD 48-02-034 Pink) or WATER SYSTEM {EHD 46-02-003} form must be completed for eacb END regulated operation at <br /> I QCAnON except UST Program(Use SWRCB forms) <br /> EHD 48-02-035 Masterfile Record <br /> 8/19/08 <br />