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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT C iTERFILE RECORD INFORMATION FOF. SHADED SECDONS FOR EHD USE ONLY OWNER ID# ,ry`7 `{ CASE !/ OWNER FILE COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION', CHECKrF OWNER CURRENTLYON FILE wim EHD❑ BUSINESS PHONE: � OWNER'S NAME Fimt ^ I ( MI T Last I L '� � 7 -j BUSINESS NAME(Ifdi1(ereUrr,..r.•-- Soc Sec orTax ID# C v/Z T0 PA OWNER'S HOME ADDRESS ( It ICJ CITY LB $ zIP r�, OWNER'S MAILING ADDRESS (If different from Owner's Address) Attention oreare of MAILING ADDRESS CITY STATE zip O(- TYPE OF OWNERSHIP: - CORPORATION ElINDIVIDUAL PARTNERSHIP I LOCAL AGENCY❑ COUNTY AGENCY LlSTATE AGENCY E] FED AGENCY L1OTHER❑ FACILITY FILE FAauT 'ID#MQp1 '7&0 CO OWNER ID#: ACCOUNT ID#VV,3'j COMPLETE THE FOLLOWING BUSINESS 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 E] BUSINESS/FACILITY NAME(This wil0. i,/y l be ih UMNESSN"- ,�I�� .�T)� / FACILITY ADDRESS(If FAa is a Moxa Fp UN/ror Fbno 14 ua u the Nmis-- Ao ) „� rt BUSINESS PHONE -f�l^IT b� w 4 ��Z e� 4//<pr� 9 S SheetN r direction Street Name StreetT Suite# / CIN(If FACIUTYIs a Moefl-E FOOD UNt�!FOOD VEHICLE n5C the COMMISSARY CITY) Sy�TE ZIP L� D (i BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 LANGADDRESS forHea/th PerMit(If DIFFERENTfrom FaafityAddle ) Attention OrCare OfADDRESS CITY STATE zip APN#: COMMENT: ACCOUNTADDRESS for fees and charges: OWNER ❑ FACILITY/BUSINESS ❑ BILLING AND COMPLIANCE ACKNOWLEDGMENT: 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 WIII be billed to me at the address identified above as the ACCOUNTADDREss 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: SIGNATURE: Please Print TITLE: DATE DRIVER'S LICENSE# PHOTOCOPY REQUIRED) Mpbvedlsv ..lJ Date i /:fi�F„� Accounting Office Process-M Completed By Dare ij3 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 8/19/08