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SAN JOA0 1'IN COUNTY ENVIRONMENTAL HEALT )FDARTMENT r.. I STERFILE RECORD INFORMATION FOI..— SHADED SECTIONS FOR EHD USE ONLY OWNER ID# ,q��QO q/D/�� CASE# (/ COMPLETE THE FOLLOWING BUSINESS WNE OWNER FILE CHECK IF OWNER CURREN71 v ON FILE wITH EH D❑ BUSINESS PHO E: n OWNER'S NAME First MI Last � BUSINESS NAME(If dffh ntfrom Owner Name) Soc Sec orTax ID# C / r Y O/`�' TOCle, ro /'!vr2 OWNER'S HOME ADDRESS Vy 12 CITU 0 r' /< _70N - + STATE zip fi 2 OWNER'S MAILING ADDRESS (If d/Ylerentfrom Owne l'S Address) Attention orCa a 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 A' ' GZ CO-OWNER ID#: ACCOUNT ID M 10 013p�J Is this a NEW Business LOCATION Of 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(This will be the BlrsorER4NAME00 the H TH PERMIT) r— /� vD lvr>L-LS crr�,�S/D� l/r,f FACILITY ADDRESS(If FAmm'is a A�LIjFccoib#rrorfb5v 1,8w Fuse the ) BUSINESS PHONE 16 rt ry� Suite# CITY(if FAC lury is a MOeAE FOOD UNrror FooO VEHICLEuaethennNefaasvrm) STATE zlp' �''`.(7 n 7 Tri CTD ✓ i BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 MAILING ADDRESS for Health Permit(If O/FFERENTfrom Fad/ityAddre ) Attention orCam Of MAILING ADDRESS CITY STATE ZIP SIC CODE: APN#: CoMMEW: dr^r°nrrafr 4DORE S for fees and charges: OWNER ❑ FACILITY/BUSINESS ❑ Riii car.AND COMPLIANCE AcRNowl FnmaFNT: 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 ADDRESS 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 Regulations. PPLICANYS AMESIGNATURE: Please Rini TITLE: DATE DRIVER'S LICENSE# (PHOTOCOPY REOUTREn) Approved By L, Data77 11 Accounting Offlce Processing Completed BY Date /B 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 CICATTON except UST Program(Use SWRCB forms) EHD 48-02-035 Masterfile Record Green 8/19/08