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SAN JOAC""M COUNTY ENVIRONMENTAL HEALTH P ,ORTMENT STERFILE RECORD INFORMATION FO. SHADED SECTIONS FOR EHD USE ONLY OWNER ID =CA)P GY O CASE# OWNER FILE OMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION; CHECKIF OWNER CURRENTLYONFILEwrTHEHD❑ BUSINESS PH NE: !f OWNER'S NAME First MI Last BUSINESS NAME(If different from Owner Name) SOC Sec OrTax ID# G / 7- p -- S- T o r M J OWNER'S HOME ADDRESS 2, Sb o NAVY CITY o G/G ra STATE ZIP �Z Q 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#: CO-OWNER ID#: ACCOUNT ID#: COMPLETE THE FOLLOWING BUSINESS FACILITY INF RMA TION: 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/FACIl NAME(This will be the BusrNESSNAMEon the HEALTH PERMIT) S ANoS lir T FACILITY ADDRESS(If Fmmrr'is a MoenEFOOo UNTror F000 /EHrcLeuse theOnmT,,;Apy ) BUSINESS PHONE r/ ��/C. C� /S �n/C�/t Suite# rNumhpr nin-rton T",Wm (IfFACILITYis OBILE FOOD UNIT or FOOD VEHICLE Use the COMMICCARY -i7v) 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: 4CCOiOVT 40DRErh for fees and charges: OWNER ❑ FACILITY/BUSINESS ❑ Rii i INT;AND CompLmNcE 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 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. PPLICANT'S AME' IGNATURE: Please Pnnt TITLE: DATE DRIVER'S LICENSE# (PHOTocopy REQUIRED) Approved By Date Accounting office Processing Completed By 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 I nrTA TnN except UST Program(Use SWRCB forms) EHD 48-02-035 Masterfile Record-Green 8/19/08