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SAN JOAQUIN COUNTYUBLIC HEALTH SERVICES • ENVIROTAL HEALTH DIVISION <br /> _ FORM (EH0016(REVISED10131100) <br /> DATE 5 —1 J <br /> — I MASTERFILE RECORD INFORMATION <br /> SJWOSEC170NSFOREHDUSC(Mr :'OWNERIG,/;:, CASEY <br /> OWNER FILE _°a a' 121 L w <br /> COMPLETE THE FOLLOW/NG BUSINESS OWNER INFORM ......................... . <br /> ATION: 1m„EHD•,....•.... <br /> ..................................... .....................................................I.................................................... .... . <br /> BUSINESS OWNER <br /> NAME <br /> .........................................................................................._............................................................................. <br /> .................................... <br /> BusimEss NAME(If dRTerenl mOwner Name) ]� L, <br /> <br /> jOWNERHOMEADDRESS IF <br /> city 1 STATE i ZIP <br /> 1 I <br /> i OWNERMAniRo ADDRESS RDIFFERENTtronl OwnerAddreae Attention:or Care of (optional) <br /> I � <br /> Melling Address City i State Zip <br /> TYPE OF OWNERSHIP: <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ <br /> r� FACILITY FILE <br /> FACILITY Will '- (/ CROSS REF IDI 11 UNT ID M <br /> COMPLETETHE.FOLLOWING BUSINESS FACILITY INFORMATION: <br /> Is this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DIVISION 7 YES ❑ NO ❑ <br /> Is this an EmSTING Business LOCATION but a NEw TYPE of regulated Business? YES ❑ No ❑ <br /> BUSINESSIFACIUTY NAME Tn14/ <br /> a ueE1HENAMEONHEALTH PERMIT -� i <br /> _ e L <br /> FACILIIYADDRESS(IFFACWTVISA MO°1LEFIXNIUMIrm FOOo lleacLEUSECAMW9SART ADDRE88) j Sum USINE88 PIM)NE <br /> 3#-3.7 S , All- rt Iva i (A021 `l'83-,3x1421 <br /> I � E <br /> CITY(F FACILIrYIeAMOB/LE Foo°UMroR Foo°VEMCLE usE S ) STATE 21P <br /> BOARDOPSUI'ERVIS°RDISTRICT oda, "Cord -: KEY1 KeY2 <br /> Mailing Address forf(e><ltir Perm1t NOIFFERENTfrvm FaclllfyAddress Attention:or Care Of(optional) <br /> Mailing Address City STA1E ZIP <br /> SIC CODE APN.I COMMENT <br /> THIRD PARTY BILLING INFORMATION: .Complete If Billing.Party is different from Business Owner.Ident%tiedabovo. <br /> ...... ............................................................... .. <br /> i Busimss NAME Attention:or Care Of (optional) <br /> I � I <br /> j Mailing Address I PHONE <br /> I I <br /> CITY CISTATE I LP I <br /> AGBBtlNZAOQRE89 <br /> for fees and charges OWNER ❑ FACILITY/BUSINESS ❑ THIRD PARTY BILLING ❑ <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify thaj I am the Owner, Operator, or Authorized <br /> Agent of this Business, and I acknowledge that all PERMIT FEES, PENALTIES, ENFORCEMENT CHARGES and/or HOURLY CHARGES <br /> associated with this Operation will be billed t0 me at the address identified above as the ACCOUNTADDRESS for this site. I also certify <br /> that all information provided on this application is true and correct; and that all regulated activities will be performed in <br /> accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/Or Standards and STATE and/or FEDLRAL Laws and <br /> Regulations. <br /> PLEASE PRINT <br /> APPLICANT NAME SIGNATURE <br /> TITLE ORIVER'S LICENSE I <br /> (PI IOTOCOPY REQUIRED) <br /> Approved OY S pate Accaunline DRlde Proceasln9 Completed BY vie.+ Data t <br />