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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT STERFILE RECORD INFORMATION FC SHADED SECTIONS FOR EHD USE ONLY OWNER ID#� /�jO 1 t,[,[G�/ CASE# OWNER (FILE COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION: CHECK IF OWNER CURRENTLY ON FILE WITH EHDEj BUSINESS ��GG� V-1 A'3 binPHONE OWNER NAME J� First MI Last BUSINESS NAME(If different from Owner Name) r i S Sec o,Tax ID# OWNER HOME ADDRESS CITY 9 � . (,.-) STATE ZIP OWNER MAILING ADDRESS (If different from Owner Address) Y J Attention or Care of MAILING ADDRESS CITY STATE ZIP TYPE OF OWNERSHIP: CORPORN,LIIRSATIOINDIVIDUAL ElPARTNERSHIP❑ LOCAL AGENCY El COUNTY AGENCY❑ STATE AGENCY El FED AGENCY❑ OTHER❑ e FACILITY FILE FACILITY ID#: 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/FACILIT'Y NAM (This will bQthe BUSAU1 kS NAME /onth�e kiEALTH PERMIT) FACILITY ADDRESS(if FACILITY isaMOBILE FOOD UN/Tor FOOD VEHICLE UsethC.OMMI.SSARYADDRESS) BUSINESS PHONE ITmbe bi ecti n l � 6i fT m Street Tvoe Suite# CITY(If FACILJTY Is MOBUNIT or FOOD VEHICLE USe the C OMMI.SSARY CITY) STATEr,Z ZIP ! ✓�^ _ N tY/ BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 MAILING ADDRESS for Health Permit(If DIFFERENT from Facility Address) Attention or Care Of MAILING ADDRESS CITY STATE ZIP SIC CODE: APN#: ✓ I I v 0 COMMENT: ACaWIV ADDRESS#or fees and charges: OWNER ❑ FACILITY/BUSINESS ❑ Rn.t.rrvr: AND C ONIPwANCF. ACKNONyuriciNiFNT: I, the undersigned Applicant, certify that I am the Owner, Operator, or Authorized Agent of this Business, and I acknowledge that all PERA11Z FEES, PENALTIES,ENFORCEMENT CIIARGES and/or HOURLY CHARGES associated with this operation will be billed tonic at the address identified above as the AccouNTADDRFss 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 Re ulations. APPLICANT NAME: SIGNATURE: Please Print TITLE: DATE DRIVER'S LICENSE# (PHOTOCOPY REQUIREDI Approved By �� Date Z Accounting Office Processing Completed By Date 4 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 10/9/2003