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SAN JOA' 'IN COUNTY ENVIRONMENTAL HEALTH f—DARTMENT 'TIMSTERFILE RECORD INFORMATION FOh. 3HADEDSEC7IONS FOR EHD USE ONLY OWNER ID# � �ll�� CASE# OWNER FILE OMPLETE THEFOLLOWING BUSINESS OWNER INFORMATION; CHECRrf,OWNER CuRRfNnYONFUEwrrHEHD❑ BUSINESS NE' I'' t7 / OWNEFist Ml Last R'S NAME 2-J J Z /- b BUSINESS NAME(If dfftvent horn Owner Name) Soo Sec OrTax ID# OWNER'S HOME ADDRESS � 7 RKe31 -rr-Hr-:,b6 RA d3 �- 1 s- / CITU (, , VT- G Gk- C I STATE I ZIP 4 L,74 gel OWNER'S MAILING ADDRESS (If&Tuventhorn Owner's Address) Alteribort arcane 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 3 CO-OWNER ID#: ACCOUNT ID COMPLETE THEFOLLowiNGBUSINESS EACILITY JWfagmuoN: I s this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO ❑ s this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ❑ BUSINESS/FACILITY NAMMb j eek NEssNAmeon the EA`T�PE SIT)! rfd v T,)4 �l�p p SL� FACILITY ADDRESS(If FAtarnris a All6te.EERaro I/MJPrFE7cv VEH Fusee lsia,rA,0 11) BUSINESS PHONE Suite# CITY(if FACILITY IS a Noelle FOOD UNIT or FOOD VEHICLE use the MMuieeeev Cm) S7 ZIP 9s3 BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 -lLJ MAILING ADDRESS for Heath Perm/t(If DmnwENrfrom Fa XyAd7ress) Attention or Care Of MAILING ADDRESS CITY STATE ZIP SIC CODE: APN#: COMMENT: Ar'r' UKr aDRECC for fees and charges: OWNER ❑ FACILITY/BUSINESS ❑ BI i iNr,ANn r.nMPi iANr..F ArKNowLcnr.MFNI: 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 to me at the address identified above as the ACCOUNT AnoRFcc 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 ulatlons. PPLICANT's NAMESIGNATURE* Please Pian[ TITLE: DATE DRIVER'S LICENSE# Aod , O Aocounting Office g 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 IXATICIN except UST Program(Use SWRCB forms) EHD 48-02-035 Ma.KM�k:Record Grccn 8!19/08