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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT fERFILE RECORD INFORMATION FOi SHADED SECTIONS FOR EHD USE ONLY OWNER ID# Q CASE# OWNER FILE COMPLETE THE FOLLOWINGBUSINESS OWNER INFORMATION; CHEcKZF OWNER CURRENTLYONFILEwrTHEHD❑ BUSINESS PHONt:q J 3173 7 3 OWNERS NAME Q / First MI Last o BUSINESS NAME(If differentfrom Owner Name) Soc Sec orTax ID# 0) OWNER'S HOME ADDRESS p 36)0 6 �� CITYf,lry _ / STATE ZIP OWNERS MAILING ADDRESS (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 ID#: p CO-OWNER ID#: ACCOUNT ID#: 3 .— COMPLETE THE FOLLOWING BUSINESS N 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 BuswwssNAMEon the HEEA�LTH PERMIT) Q /' V / S FACILITY ADDRESS(If FAcmrTY is LE�N�VtxlaEuse the COMMISSARY ADDRESS) BUS�IINESS PHO �n�7 f/jI l� Street Number/' Direction Street Name Street Type Suite# CITY(If FACILITYIs a MOB LE FOOD UNIT or FOOD VEHICLE use the COMMISSARY CITY) STATE ZIP [BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 MAILING ADDRESS fol'Health PerM t(If DIFFERENTfrom Facility Address) 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: 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 WIII be billed to 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. APPLICANTS NAME: SIGNATURE: Please Print TITLE: DATE DRIVER'S LICENSE# PHOTOCOPY REQUIRED) Approved By Date Accounting Office Processing Completed By Date" D 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