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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ERFILE RECORD INFORMATION FOI� SHADED SECTIONS FOR EHD USE ONLY OWNER ID# L' �t �! '- CASE OWNER FILE COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION; CHECKIF OWNER CuRRENTLYON FrLE wrTH EHD❑ BUSINESS PHONE: OWNER'S NAME First Ml Last BUSINESS NAME(If dltf, ntfrom Owner Name) Soc Sec orTax ID# IG A A!J OWNER'S HOME ADDRESS , 5 , Z CIN A L N D L,� STATE ZIP 4?S�lryo OWNER'S MAILING ADDRESS(If d9Terentfrom Owner's Address) Attention orCare of MAILING ADDRESS CIN STATE ZIP TYPE OF OWNERSHIP: CORPORATION❑ INDIVIDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ FACILITY FILE FACILITYID#:. -"'/ % CO-OWNERID#: ACCOUNTID#: COMPLETE THE FOLLOWING BUISIN ESS FACILITY INFORMATION: 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 Is will be the BusrxtxsNAM on the HEA HPERMIT) FACILITY ADDRESS(IfFAm i Mpetc )`Wo or VEKi use eCO mr av N!V I y � �b J .�-M BUSINESS PHONE IX 4,U Street Number ./ Direction / Street Name lJ�✓� Stteet T suite# CIN(If FACILmIsaMoelLEFoo4 LINIT or FOOD i�cLEuse the CoumissaRYCITYI ST97E ZIP_�� BOARD OF SUPERVISOR DISTRICT R/'T'/' LOCATION CODE KEY1 �+ KEY2 /q MAILING ADDRESS for Health PeFmyt(If DIFFERENTfrom FadlilyAddms) Attention or Care Of MAILING ADDRESS CIN STATE ZIP SIC CODE: � APN 4: COMMENT: ACCOUNTADDRESS for fees and charges: OWNER ❑ FACILITY/BUSINESS ❑ BILLING AND COMPLIANCE ACKNOWLEDGMENT: [,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 ACCOUN-ADDRESS for this site. 1 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 Regulations. APPLICANT'S NAME: SIGNATURE: Please Pdnt TITLE: DATE DRIVER'S LICENSE# PHOTOCOPY REQUIRED) Approved BY - DateAccounting Office4rocessing Completed ey Date t 2. i A PROGRAM {EHD 48-02-034 Pink} or WATER SYSTEM {EHD 46-02-0031 form must be completed for each EHD regulated operation at this LOCATION except UST Program(Use SWRCB forms) EHD 48-02-035 Masterfile Record Green 8/19/08