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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT TERFILE RECORD INFORMATION FOF SHADED SECT/ONSFOR EHD USE ONLY I VWNERID# C� p �}J/_ ©�� CASE# G/ OWNER FILE COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION: CHECKIF OWNER CURRENTLY ON FILE WITH EH D❑ BUSINESS �C✓� L— �,� PHONE: OWNERS NAME First MI Last BUSINESS NAME(If differentfrom Owner Name) SOC Sec orTax ID# -- 0"'I ' 7 2 OWNER'S HOME ADDRESS CITY STATE ZIP OWNER'S MAILING ADDRESS (If different from Owner's Address) Attention or Care of I' l 2I 'C o 0 6 C / 2 S �v bti -C -t- MAILING STATE zip TYPE OF OWNERSHIP: CORPORATION INDIVIDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ FACILITY FILE FACILITY ID#-r09 IFI CO-OWNER ID#: ACCOUNT ID#: 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 ❑ BUSINESS/FACILITY NAME(This will be the BusrNEssNAMEon the HEALTH PERMIT) S GL a✓-L FACILITY ADDRESS(If FAcrLmis a MOsILEFooD UNrror FOOD VEHLCLEUse the COMMISSARY ADDRESS) BUSINESS PHONE S p Gt.S e-k tJQ✓�_ Street Number Direction Street Name Street Tyge Suite �— CITY(If FACILITY Is a MOBILE FOOD UNIT or FOOD VEHICLE Use the COMMISSARY CITY) STATE zip BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 MAILING ADDRESS for Health Permit(If DIFFERENTfrom Facility Address) Attention or Care Of MAILING ADDRESS CITY STATE zip [SIC CODE: 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 will be billed t0 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. y� APPLICANTS NAME: �.S'CR G OL�� alt Z SIGNATURE: Please Print ) Approved By Date Accounting Office Processing Completed By jf Date •) A PROGRAM {EHD 48-02-034 Pink} or WATER SYSTEM {EHD 46-02-0031 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