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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT JERFILE RECORD INFORMATION F( SHADED SECTIONS FOR EHD USE ONLY OWNER ID# ,t//_D =CASE# OWNER FILE COMPLETE THE FOLLOWING BUSIN ESS OWNER INFORMATION: CHECK IF OWNER CURRENTLYONFILE WITHEHD❑ BUSINESS J3r/ Al rgI/i A/ Z AP ONE: OWNER'S NAME First MI Last Z.O v 0 BUSINESS NAME(If difierentfrom Owner Name) SoC SeC OrTax ID# o, 0 a T OWNER'S HOME ADDRESS CITY C� STATE ZIP C�D OWNER'S MAILING ADDRESS (If different from Owner's Address) Attention orCare of MAILING ADDRESS CITY STATE ZIP TYPE OF OWNERSHIP: CORPORATION❑ INDMDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ FACILITY FILE FACILITY ID#:�P CO-OWNER ID#: ACCOUNT ID#: COMPLETE THE FOLLOWING BUSIN ESS 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(If FAQLITY is a Moer[EFooD UNrror FooD�&aaEuse the CoMMi A ) BUSIN H7E ,7 AF 14qtNumber Direction Street Name StreetT e Suite# CITY(If FAciLtrvls a MOBILE FOODU ITor Fo D VEHICLE use the COMMISSARY CITY) STATE ZIP G / L' Iq L10�9 air BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY'I KEY2 MAILING ADDRESS for Health PerMit(If DIFFERENTfrom FacilityAddress) 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: 1,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 WIII be billed to me 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 Regulations. APPLICANT'S NAME: SIGNATURE: Please Pnnt TITLE: DATE DRIVER'S LICENSE# PHOTOCOPY REQUIRED) Approved By ct Date / 1 Cj Accounting Office Processing Completed By Date e q �Z 11 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 8/19/08