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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ,TERFILE RECORD INFORMATION FC SHADED SECTIONS FOR EHD USE ONLY OWNER ID# r CASE# OWNER FILE COMPLETETHE FOLLOWINGBUSINESS OWNER INFORMATION; CHECKIF OWNER CURRENTLYONFTLEwITHEHD❑ BUSINESS PHONE: OWNERS NAME First Ml Last BUSINESS NAME(If differentfroowner Name) �. Soc Sec orTax ID# TfA? oi � Ct3 r ;, OWNER'S HOME ADDRESS 2 '7 Di ' /� lw� r itAl CITY r- 0�t� „� $TATE ZIP 1 OWNER'S MAILING ADDR SS (If different from Owner's 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 I ? SOU CO-OWNER ID#: ACCOUNT ID#:,9 (( r 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 BusmEssNAmEon the HEALTH PERMIT) FACILITY ADDRESS(IfFAcIglyisaMc7etcEfaoD1/NirorFaa ajms eo SARYADDR �/ / � LLJ71/ GG��. �-+yy . BUSINESS PHONE Street Number Direction Street Name Street TVDe Suite# CITY(if FACILITY is a Moea °OD OMIT/Or D VEHICLE USe the COMMISSARY CITY) y rMTf zip [BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 MAILING ADDRESS fOr Health Perm/t(If DIFFERENTfrom FacilityAddress) Attention or Care Of MAILING ADDRESS CITY STATE ZIP SIC CODE: APN#: COMMENT: AccomyrADDRE55 for fees and charges: OWNER ❑ FACIUTY/BUSINESS ❑ BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and 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. APPLICANT'S NAME: SIGNATURE: Please Print TITLE: DATE DRIVER'S LICENSE# PHOTOCOPY REQUIRED) Approved By j fj Date f / Accounting Office Processing Completed By Date t n /I ep C� 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