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SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH PFPARTMENT <br /> %.iSTERFILE RECORD INFORMATION F(%.J <br /> SHADED SECTIONSFOREHDUSE ONLY OWNER ID# CASE# <br /> OWNER FILE <br /> OMPLETE THE FOLLOWING USINESS MN EIRNFORMATION' CHECKIFOWNER CURREMIYONFILEWIIHEHD❑ <br /> BUSINESS ONE' <br /> OWNERS NAME First M1 Last L 7j <br /> BUSINESS NAME(If different from owner Name) Soc Sec orTax ID# <br /> Z p Gvi �G A✓C-) <br /> OWNER'S HOME ADDRESS (/ <br /> CITY WVA LA�U '� G r k !Y STATE Z[P 19 <br /> CiWNERyS(HAILING ADDRESS (If diffemnthnmOwner'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 /> 11 FACIUTY ID#: CO-OWNER ID#: ACCOUNT ID#.Z9,t9,33fJ s <br /> PLETFrHFFoLLowwyG1BUS1N <br /> IS this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT".1 YES ❑ NO ❑ <br /> IS this all EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ NO ❑ <br /> BUSINESS FACILITY NAM (This will be the zsfNAaEon the HEALTH IRERM <br /> FACILITY ADDRESS(If FAaLrTyis a AloxLEFOOD Uurror Fow N iaEuse e ) h NE <br /> Q! <br /> / c7 ` U�ri7O� ep <br /> Z.0 S-7 / 1 a �d <br /> Suite# <br /> CITY(if FACILrrYIS a MOBILE FOOD UNrr or FOOD VEHICLE us the COMMISSARY r'rrv) STA ZIP <br /> ,, J <br /> S G0 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE EEY1 KEY2 <br /> MAILING ADDRESS for Health Permft(lf DffFERENTfrom F-11tyAddreas) Attention orCare Of <br /> MAILING ADDRESS CITY STATE ZIP <br /> SIC CODE: APN : CDMMENr: <br /> 4CCOL r M df]DRE.Ef for fees and Charges: OWNER ❑ FACILITY/BUSINESS ❑ <br /> BILLING AND COMPLIANCE ACKNOWLFDGMFNT. 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 ACCOUNT AOnREss 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 /> APPLICANT'S NAME• IGNATURE <br /> Please Print <br /> TITLE: DATE DRIVER'S LICENSE(PHOTOCOPY REQUIRED) <br /> # <br /> Approved By �. Date Accounting Office Processing Completed By Date It 1 <br /> 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 <br /> I OCATION except UST Program(Use SWRCB forms) <br /> EHD 48-02-035 Masterfile Record-Green <br /> 8/19/08 <br />