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SAN JOA"'IIN COUNTY ENVIRONMENTAL HEALTH -PARTMENT TwSTERFILE RECORD INFORMATION FOR,,. SHADED SECTIONS FDREHD USE ONLY OWNERID# DO�L17 CASE# OWNER FILE OMPLETE THE FOLLOWING BUSINESS QWN ER INFORNATION• CNECKIF OWNER CURRENn r ON FILE WITH EH D❑ BUSINESS PHONE: OWNER'S NAME First MT Last r+ �_ BUSINESS NAME(If 6Yf0•ent horst owner Name) Sot SDC orTax ID At 7-Z if Gn Lot✓ OWNER'S HOME ADDRESS /// / CITY :f C A LQN STATE ZIP L. U 2—dOWNER'S MAILING ADDRESS di/leYent hers Address) Attention OrCare of CITY C s`C 14 GQry /C /4 STATE DP MAILING ADDRESS TYPE OF OWNERSHIP: f 1. v i CORPORATION❑ TNDMDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY G STATE AGENCY❑ FED AGENCY❑ QTHER❑ FACILITY FILE FACILITY ID#: ( CO-OWNER ID#: ACCOUNT ID#: R N' Is this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No ❑ Is this an EMSTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ❑ BUSINESS FACILITY NAME(Thi will be the BNSfNESSNAMEon the H LTH P _scAL0� , T ' cF v �T, �VOle S 141.,F # 10 FACILITY ADDRESS(If FAotTrY i a hklaltERxo UNrro Fro aeuse the c'rwMI� Ry Arrnccc n n)M 46r ` & X 0��, y /� X�F BUSINESS PHONE L—OY tJ /J/� f-' Suite 77 CITY IN FAcivrY is a Mo LE FOOD UNMo( OD VEHICLE use the COMMISSARY C.m) STAT&f„a ZIP /} T— Z `7 d11_ BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY/ = KEY2 MAILING ADDRESS for Health Permii OTFFERENrfrom FacitityAdonez) Attention or Care Of MAILING ADDRESS CITY STATE ZIP SIC CODE: APN#: CDNMIXr; A!Y-n//NT An0gESS for fees and Charges: OWNER ❑ FACIUTY/BUSI NESS ❑ Ru i w0 ANn CnMP1 ANC ACRNGWI En.M T: 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 A C .O INTADDRERc 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. APPLICANT'S NAME.• SIGNATUREd R'ease Print TITLE: 1 DATE DRIVER'S LICENSE# APProYed By '// Date,a Zy Acooumhrg Off ca Processing Completed By Date A PROGRAM (EHD 2-034 Pink) or WATER SYSTEM (EHD 46-02-003) form must be completed for each EMD regulated operation at this I GrATION except UST Program(Use SWRCB forms) EHD 48-02-03S Masterfile Record Green 8/19/08