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SAN JOA(4 COUNTY ENVIRONMENTAL HEALTH I''---ARTMENT NfASTERFILE RECORD INFORMATION FOS SHADED SEC77ONS FOR EHD USE ONLY OWNER ID# CASE# OWNER FILE COMPLETE THEFOLLOVKNG BUSINESS OWNER lwoRMATION: CNECKIF OWNER CURRENTLY ON FILE KITH EHD BUSINESS PHONE OWNER NAME First Mt Last or Tax ID# ATedj OWNER HOME ADDRESS 3 9d CITY — STATE ZIP S�D OWNER MAILING ADDRESS (If different from Owner Address) Attention or Care of MAILING ADDRESS CITY STATE ZIP TYPE OF OWNERSHIP: CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ FACILITY FILE FACILITY ID#: fqq CO-OWNER ID#: ACCOUNT ID#:4W(3 l 'r COMPLETE THE FOLLOVONG BUSINESS FACILITY INFORMAnON: 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 ❑ BUSINESS FACILITY NAME(This 'I the BUSINESS NAMEon the HEALTH PERMIT) VV FACILITY/Z.,D I�FAC1� MpBI(F D LINfTp/F�Opp 1fQ use the t nn+nnl.�SARY ArsnRFccY BUSINESS PHONE Z i ��J{ ,,/ Suite# Street Number reck)n Stmet Nam Street Type CITY(if FACr�a MOWLE FOOD UNrr or FOOD VEMCl.E use the r.Q=%SARx r_=) STATE.- ZIP �y BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 MAILING ADDRESS for Health Permit(if bfFFERENT from FaciliiyAddress) Attention or Care Of MAILING ADDRESS CITY STATE ZIP SIC CODE: APN#: COMMENT: ArMINTADDRESfor foes and charges: OWNER ❑ FACILITY/BUSINESS ❑ IRujjNr: Arras CompijANCF, ACKNOWLEDGMENT: I, the undersigned Applicant, certify that I am the Owner, Operator, or Authorized Agent of this Business, and I acknowledge that all PERMIZ,FEES,PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation will be billed to me at the address identified above as the AccouNTADDRfor 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 Re ulations. APPLICANT NAME: SIGNATURE: Please PAW TITLE: DATE DRIVER'S LICENSE# Approved By Data PVZ-7 LLi Accaunting Office Processing Completed By Date 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 I ON except UST Program(Use SWRCB forms) EHD 48-02-035 Masterfile Record-Green 10/9/2003