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SAN JOAO' -N COUNTY ENVIRONMENTAL HEALTH DFPARTMENT ` ASTERFILE RECORD INFORMATION FO%ssw SHADED.SECTIONS FOR EHD USE ONLY T OWNERID# B600iaq �# OWNER FILE OMPLE7E TN EFOLLOWING_BUSINE55 NFORMATION' Q/ECKIF OWNER CURREMTZYON ffLE wmrEHD❑ BUSINESS PHONE: OWNER'S NAME Fest MI Last BUSINESS NAME(If dllkYentlmrn Owner Name SOC Sec OTTaX ID# Fen T o Gooi OWNER'S HOME ADDRESS /2,,S- I STO C j�PA-J CITY O STATE zip OWNER'S MAILING ADDRESS (If different from Owners Address) Attention oreare of MAILING ADDRESS CITY STATE zip TYPE OF OWNERSHIP: CORPORATION❑ INDIVIDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ FACILITY FILE `/ p FACIUTY ID#:Dp I �T 1 7 CO-OWNER ID#: ACCOUNT ID#:Hall f ComaETE F IS this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO ❑ IS this an E%ISRNG Business LOCATION but a NEw TYPE Of regulated Business? YES ❑ NO ❑ BUSINESS/FACILITY�IAIME(Th ill e the 8 O on the HEALTH PERM), -2— FACILITY L Z FACILITY ADDRESS(If FA(EIn'is a MO6AEFa U%1/rTaOr VH os se the A,!!)A// BUSINESS PHONE 2O ( .f j6 k,opt Suite n CITU(If FAaurrna osl�FOOUUNIror FboolAn NCLEuse the CnN%%mYrrt STATE zip d BOARD OF SUPERVISOR DIsmcr LOCATION CODE =EY1 KEY2 MAILING ADDRESS for Hea/t/I Permit(lf DLFFERENTfrom FadlRyAcbr ) Attention or Care Of MAILING ADDRESS CITY STATE zip SIC CODE: APN#: CAMME—. drrnrrArr ZMWZE5e for fees and charges: OWNER ❑ FACILITY/BUSINESS ❑ flu I iNr.ANn COMP IANrF AcKNOWI FnrMFNT: 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 ACCOUNTADDRFSc 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. PPLICANT'S AME' NATURE' Pledse Pnnt TITLE: DATE DRIVER'S LICENSE# Approved Sy e Data '� Acoxintin9 Office Processing Completed By pate H A PROGRAM (EHD 48-02-034 Pink) or WATER SYSTEM {EHD 46-02-003} form must be completed for each EHD regulated 'on at this i nrsrrnN except UST Program (Use SW RCB forms) EHD 48-02-035 Masterfile Record{Green 8/19/08