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SHADED SECTIONS FOR EHD USE ONLY <br />SAN JOA01 IIN COUNTY ENVIRONMENTAL HEALTH P-1ARTMENT <br />.ASTERFILE RECORD INFORMATION FL <br />OWNER ID # �, �� r, -� �- j CASE # <br />e 'L <br />COMPLETE7-1—OLLOW/NGBUSINESS OWNER INFORMATION: <br />CHECK/F OWNER CURRENTLYON FILE WITH EHD❑ <br />TYPE OF OWNERSHIP: <br />CORPORATION ❑ INDIVIDUALV PARTNERSHIP ❑ LOCAL AGENCY ❑ COUNTY AGENCY ❑ STATE AGENCY ❑ FED AGENCY OTHER ❑ <br />FACILITY FILE <br />FACILITY ID #: Co -OWNER ID #: ACCOUNT ID #: <br />COMPLETE THE FOLLOW/NGBUSINESS FACILITY INFORMATION.' <br />IS this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES ❑ NO ❑ <br />r1C..DTUCur9 <br />Is this an ExISTING Business LOCATION but a NEw TYPE of regulated Business? YES ❑ <br />tJWrr <br />, <br />PHONE: <br />I (/ <br />BUSINESS <br />OWNER'S NAME <br />Fest <br />MI <br />Last <br />BUSINESS NAME (If different from Owner NarOW <br /> # <br />OWNER'S HOME ADDRESS I �. [A <br />CITY o s <br />Y "� <br />STATE <br />ZIP <br />OWNER'S MAILING ADDRESS (If different from owneesAddress) <br />Attention or Care of <br />MAILING ADDRESS CITY <br />STATE <br />ZIP <br />TYPE OF OWNERSHIP: <br />CORPORATION ❑ INDIVIDUALV PARTNERSHIP ❑ LOCAL AGENCY ❑ COUNTY AGENCY ❑ STATE AGENCY ❑ FED AGENCY OTHER ❑ <br />FACILITY FILE <br />FACILITY ID #: Co -OWNER ID #: ACCOUNT ID #: <br />COMPLETE THE FOLLOW/NGBUSINESS FACILITY INFORMATION.' <br />IS this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES ❑ NO ❑ <br />r1C..DTUCur9 <br />Is this an ExISTING Business LOCATION but a NEw TYPE of regulated Business? YES ❑ <br />NO ❑ <br />BUSINESS/FACILITY NAME (This will be the ausifwssNAMEon the HEALTH PERMIT) 1 <br />FACILITYADDRESS (If FAculrYls a hfoalLEF000 UNiror FooD VEHICLEUS8 the COMMISSARY ADDRESS) <br />B�USSjINESS PHONE <br />Dlil A�- <br />/'� \ y� ("G 2 L <br />aame <br />suite � <br />CITY (If FACILITY IS a MOBILE FOOD UNIT or FOOD VEHICLE use the CommisSARY CITY) <br />STATE <br />ZIP <br />BOARD OF SUPERVISOR DISTRICT LOCATION CODE 1•- . <br />KEY/ <br />I<EY2 <br />MAILING ADDRESS for Health Permlt(If D/ FE, from Faci/ityA ress) <br />T)e Are <br />Attention orCare Of <br />MAILING ADDRESS CITYi .GfL` <br />STATE /i <br />( <br />ZIP <br />/ <br />17177, <br />COMMENT: <br />SIC CODE: <br />APN aY l-! <br />ACCOUNTADORESS for fees and charges: OWNER FACILITYIBUSINESS ❑ <br />BILLING AND COMPLIANCE ACKNOWLEDGMENT: I, the undersigned Applicant, certify that I am the Owner, Operator, or Authorized Agent of this Business, and <br />I acknowledge that all PERMIT FEES, PENALTIES, ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation will be billed to me at the <br />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 <br />all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or <br />FEDERAL Laws and Regulations. <br />APPLICANT'S NAME: 'OWb& SIGNATURE: <br />� <br />y Print DRIVER'S LICENSE # <br />TITLE: 9 AI t _. 77i DATE in.,..r.,. -, <br />N Approved By ? r p I,/'�1 -- I Date �' -, II Accounting Office Processing Completed By <br />A PROGRAM {EHD 48-02-034 Pink) or WATER �YsTEM (EHD 48 -OZ 1J m tne*be completed for each EHD regulated operation at this LOCATWk <br />except UST Program (Use SWRCB forms) <br />EHD 48-02-035 Masterfile Record -Green <br />8/19108 <br />