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h SAN JOAQUIN COUNTY.ENVIRONMENTAL HEALTH DEPARTMENT ' ;TERFILE RECORD INFORMATION FOI >: . _ �- :�_:.� .- - .,.. � �,:�� r _:;° �:�.� gym.: -� `;°'•�. � �= SHADED SECTIONS FORl:HDUSE ONLY OWNE'ID OWNER FILE COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION: CHFCKrF OWNER CuRaENnyoNFrcEwnNEHD❑ BUSINESS f7 PHONE: OWNER'S NAME !/ Za -3 [— ( first M7 Last ,� BUSINESS NAME(If different from Owner Name) SOC Sec orTax ID# A5 5 T9ua4,,mk OWNER'S HOME ADDRESS SD 46&1'1V CITY C C/1 I STATE ZIPS3 OWNER'S MAILING ADDRESS (If different from Owner's Address) Attention or Care of J MAILING ADDRESS CITY STATE ZIP TYPE OF OWNERSHIP: CORPORATION❑ ]INDIVIDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ FACILITY FILE FACILm'10# r c m Go-;?WNEK tD#: _ _ _-- _ACCOU,NT ir3#: _ COMPLETE THE FOLLOWING BUSINESS FACILITY INFORMATION: I5 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 ❑ BUSINESS/FACILITY NAME(This will be the BusrxEss th ffAmEon Al ��HEALTH P RG JA1 FACILITY ADDRESS(If FaCturr is a MasrcEFaOD UNrrar Foca Vr7it use the COMMISSARY ADDRESS) BUSINESS PHONE Street Number Direcrion Street Name Street T Suite# CITY(if FAaLtrris a Moa7LE FooD UNIT or FooD VEHICLE use the CommissARY CirY) STATS ZIP ^ J D BOARD OF SUPERVISOR iDISTRICT LOCA TIONCODE Y 'tet i KEY I _ �KEY2 - MAILING ADDRESS fOr Health Permit(If DIFFERENT€rom Facility Address) Attention orCare of MAILING ADDRESS CITY STATE ZIP AR i :a SIC CODE. APN#:Ar 3COMMeNT:' _ $' for fees and Charges: OWNER ❑ FACILITY/BUSINESS ❑ BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and 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. APPLICANT'S NAME: SIGNATURE: Please Print TITLE: DATE DRIVER'S LICENSE# PHOTOCOPY REQUIRED) Approved By N� =i Date Accuunting OFfice.Pratessing Completied By ate &I'S& ..' A PROGRAM {EHD 48-02-034 Pink} or WATER STEM {EHD 46-02-0031 form must be completed for each EHD regulated operation at this LOCATION except UST Program(Use SWRCB forms) EHD 48-02-035 Masterfle Record-Green 6/19/08