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SAN .JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT .STERFILE RECORD INFORMATION F(.. SHADED SECTIONS FOR EHD USE ONLY OWNER ID# B'e f036CASE# OWNER FILE COMPLETE THEFOLLOW/NGBUSINESS OWNER INFORMATION; CHEcKtF OWNER CURRENTLYONFiLEwiTHEHLD/ rBUSiNEss P ONE AME First MI Last AME(8differentfremOwner Name) Soo Sec or Tax # CA EGHOME ADDRESS O Q r CITY .-,%vAA179 GA STATE ZIP s OWNER MAILING ADDRESS (ff different from Owner Address) Attention or Care of MAILING ADDRESS CITY STATE ZIP TYPE OF OWNERSHIP: CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY OTHER❑ FACILITY FILE p. FACILITY ID#: CO-OWNER ID#: ACCOUNT ID#: p COMPLETE THE FOLLOWING BUSINESS FACILITY INFORMATION.- Is NFORMATION.Is this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES ❑ NO ❑ Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ❑ BUSINESS/FACILITY NAME(This will be the HUS/NESS NANEOn the#ALTH PERMIT) "—f/; C yv r Lei F/ Z FACILITY ADDRESS(NFACnrTYis a MOHILFFOOD UNrror FOOD VEHi E ether a AO Fes) BUSINESS PHONE 3 S� Lv� r3�R0 Suite# CITY(If FACI�UnTYm a MOSeEMOD UNrror F000 VENICa use the CO•�KSMARY C $TATE ZIP^�� 3� 141Q/V T�(j CANt, BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEYT KEY2 MAILING ADDRESS for Health Perm/t(If OIFFERENTfrom Facility Address) Attention or Care Of MAILING ADDRESS CITY STATE ZIP SIC CODE: APN#: a a� COMMENT: ACRONNTADDRF.CRfor fees and charges: OWNER ❑ FACILITY/BUSINESS ❑ BuT.mr, AND CoNipr.IANCR ACKNOWI.E.DGmENT: 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 ACCOUNTADDRECs 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. APPLICANT NAME: SIGNATURE: Please Print TITLE: DATE DRIVER'S LICENSE# Cl Approved By C - 9 Date �3 Q Accounting Office Processing Completed Byilv Date a 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 LOCATION except UST Program(Use SWRCB forms) EHD 48-02-035 Masterfile Record-Green 10/9/2003