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h SAN JOA^IJIN COUNTY ENVIRONMENTAL HEALTH r 'PARTMENT ASTERFILE RECORD INFORMATION kivi SHADED SEC77ONS FOR EHD USE ONLY OWNERID# OWNER FILE OMPLETETMEFOLLOWINGBUSINESS INFORMATION; 0iFCtrrFOWNER CURRENnyoNFILEwmrEHD❑ BUSINESS PHONE: OWNER'S NAME First M7 Last BUSINESS NAME([f drtfemntfiom Owner Name) Sac SeC Or Tax ID# o T OWNER'S HOME ADDRESS 7 90 ?OIVNCrr CITY STATE ZIP OWNER'S MAILING ADDRESS (If dilferentfmmOwner's f/Address) Attention orCare of MAILING ADDRESS CITY STATE ZIP TYPE OF OWNERSHIP: CORPORATION❑ INOMDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ FACILITY FILE FACILITY ID#: CO-OWNER ID#: ACCOUNT ID M 2, ETE THE L A 0WING B U A I N E S S E A C I LKEY ANFORAM Is this a NEW Business LOCATION or VEHICLE-lot 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 BusvmssAkmeon the HEALM PERMIT) FACILITY ADDRESS(If - - -FACm TYIS a M' a'�Fccv 1lll.Fay I�ICteuse the rnmwT—Arzy ArAwFcc) BUSINESS PHONE I Zl/ T RAY Gfio�d �2 Suite# CITY(If FAuurris 9,MOBILE FOOD UHrror FOOD VEMCLE use the Qmm1-RcAcev r'irv) ST ZIP A BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 MAILING ADDRESS for Health Permit(If DIFFERFNTfrom c8alttyAddress) Attention orCare Of MAILING ADDRESS CITY STATE ZIP SIC CODE: APN#: Commew: A9=1 r-4W E55 for fees and charges: OWNER ❑ FACILITYIBUSINESS ❑ RII I INr ANn rump!IANCF OCKNOWI FnCMFNT: 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 and/or HOURLY CHARGES associated with this operation will be billed tome at the address identified above as the ACCOUNT An 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 Re ulations. PPLICANT'S NAMEN 51 Please PrOt TITLE: DATE DRIVER'S LICENSE# Approved By e i Date Z v Accounting Office Pwoessing Completed By Date A PROGRAM {EHD 48-02-034 Pink} or WATER SYSTEM (EHD 46-02-003) form trust be completed for cacti EHD regulated operation this I OCATION except UST Program(Use SWRCB forms) EHD 48-02-035 Masterfile Record-Green 8/19/08