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SAN JOf -"N COUNTY ENVIRONMENTAL HEALTE. "ARTMENT I1,,ASTERFILE RECORD INFORMATION Fot—, SHADED SECTIONS FOR EHD USE ONLY [::0:W:NjER1D# QO/ �j CASE# OWNER FILE COMPLETE THE FOLLOWING BUSINESS OWNERINFORMATION: CHECKIF OWNER CURRENTLY ON FILE WITHEHD BUSINESS PHONE —7 OWNER NAME First MI Last 3 / 3 J BUSINESS NAME(If different from Owner Name) •/ Soc Ser Or Tax ID# G / l Y D T- 7-6 C_ C. OWNER HOME ADDRESS 250D NPV Y CITY 5 Z'0 G /<� fa 14/ STATE ZIP OWNER MAILING ADDRESS (If different from Owner Address) Attention or Care of MAILING ADDRESS CITY STATE ZIP TYPE OF OWNERSHIP: CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ FACILITY FILE FACILITY ID#: OD CO-OWNER ID#: ACCOUNT ID#: COMPLETE THEFOLLOW/NG 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 Crhiswill be the BUS/NESSNAMEonthe HEALTH P MIT) �/�n� ? v� w� IVE C� ro; Sa /7 y sJ i FACILITY ADDRES (ff FACILITY Is a MOBILE FOOD UNIT or FOOD VEHIC/L /E use the CoMMISSAR/YY ADD,DRRrSS) BUSINESS PHON �7 /y / �/� C-O&V lz I VIZ 16i / S �/�-/7`/Stre, DireCUM Street Name �treet T Suite# / J 2^ / T v CITY(If FACILITY is a MOBILE FOOD UNIT Or FOOD VEHICLE use the C.0mm".55ARY C.nv) STATE ZIP BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEPI [� KEY2 MAILING ADDRESS for Health Permit(if DIFFERENT from Facial Address) Attention or Care Of MAILING ADDRESS CITY STATE ZIP SIC CODE: APN#: COMMENT: Ar f'n11NT AQQRFSR for fees and charges: OWNER ❑ FACILITY/BUSINESS ❑ Bi1.1.INC: AND C ONTPI.IANCF ACKN0w1.FDGM1tFNT: I, the undersigned Applicant, certify that I am the Owner, Operator, or Authorized Agent of this Business, and I acknowledge that all PERMq FEES,PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation will be billed tome at the address identified above as the ACCOUNT ADDRESS 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 REOUIRED) Approved By �.6 Date 3 Accounting Office Processing Completed By Date 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 except UST Program(Use SWRCB forms) EHD 48-02-035 Masterfile Record-Green 10/9/2003