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SAN JOAQUN COUNTY ENVIRONMENTAL HEALTH DF-PARTMENT <br /> ' '"' 1STERFILE RECORD INFORMATION Fob$ <br /> SHADED SECAONSFOR EHD USE ONLY OWNER ID# CASE# <br /> OWNER FILE <br /> OMPLtTETHEFOLLOWINGBUSINESS OWNERNFORMATION QfEcirrF OWNER CURRENrcraNFrcE H7rHEHD❑ <br /> BUSINESS PHONE'/ 77 <br /> OWNER'S NAME First MI Last / L/00 <br /> BUSINESS NAME(If differentfmm Owner Name) Sot Sec orTax ID# <br /> C / rA 0 <br /> k <br /> OWNER'S HOME AflDRE SS jy nl>, <br /> CITY STATE ZIP 9s3 7 <br /> OWNER'S MAILING ADDRESS(If dr rent from Owner's Address) Attention arCare 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 /> } <br /> FACILITY FILE <br /> FACILITYID#: p� CO-OWNER ID#: ACCOUNT ID#: <br /> COAr <br /> PrNFORAM 7100y. <br /> Is this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No ❑ <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ❑ 17 <br /> BUSINESS/FACILITYy NAME is will be the �N4mEon the HEALTH PERMIT) <br /> h Z , i �✓ <br /> FACILITY ADDRESS(If FAaurris a Mo82ErDCD UA ror FOW V&ff¢Euse the Camrmccnav Arrnm BUSINESS PHONE <br /> 1 05* 7'-'2AV44 T/A, <br /> Surto# <br /> CITY(If FACILITY r3 8 MOBILE FOOD UN or FOOD VEHICLE use the rnMMrc3Aa (Crrv) ST ZIP <br /> C/j�L'71, <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> MAILING ADDRESS for Heath Permlt(If oiFFERENTfrom FadlityAddress) Attention orCare Of <br /> MAILING ADDRESS CITY STATE 7JP <br /> SIC CODE: APN#: COMMENT: <br /> S <br /> AC=Mr for fees and charges: OWNER ❑ FACILITYIBUSINESS ❑ <br /> BH_LINrANO COMPI IANCF ArKNOWLFDrMENT: I,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 ACCOUNT An ss 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 JOAOUIN COUNTY Ordinance Codes and/or Standards and STATE and/or <br /> t FEDERAL Laws and Regulations. <br /> PPLICANT'S AME I NA RE• <br /> Please Print <br /> TITLE: DATE DRIVER'S LICENSE# <br /> (PHOTOCOPY RFotjxgFn) <br /> Approved By �f Date D� Accounting Office Processing Completed By Date �7 Q <br /> A PROGRAM (EHD 48-02-034 Pink) or WATER SYSTEM (EHD 46-02-003) form Dues# be completed for eft EHD regulated operation at this <br /> I nCATTnN except UST Program(Use SWRCB forms) <br /> EHD 48-02-035 Masterfile Record-Green <br /> 8/19/08 <br />