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SAN JOA COUNTY ENVIRONMENTAL HEALTH D4RTMENT <br /> ri"i7CSTERFILE RECORD INFORMATION FOR, FI <br /> SHADED SECTIONS FOR EHD USE ONLY OWNER ID# k) RD <br /> b O�zBCASE# L <br /> OWNER FILE <br /> COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION: CHECK IF OWNER CURRENTLY ON FILE WITH EHD <br /> BUSINESS �� n PHONEj <br /> OWNER NAME FInt M/ Last �- r — .J 7 <br /> BUSINESS NAME(If dAferent Gan Owner Name) Soo Sec or Tax ID# <br /> 1 nn <br /> OWNER HOME ADDRESS <br /> CITY - STATE ZIP <br /> OWNER MAILINGRESS (If different from Owner Address) Attention or Care of <br /> va �DX q06 <br /> MAILING ADDRESS CIN O ST ZIP S 3 <br /> TYPE OF OWNERSHIP: <br /> CORPORATION INDMDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID#: gpZ CO-OWNER ID#: ACCOUNT ID#: <br /> COMPLETE THE FOLLOWING BUSINESS FACILITY INFORMATION: <br /> Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES lia No ❑ <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ NO <br /> BUSINESSIFACILITY NAME(Thi fill be the eusr,Ess NAUEon the <br /> D HEALTH PERM T) <br /> FACILITY ADDRESS(if FAcun-Y is a mooLEF000 Uwar FOOD VEHICLLEEa1 the CA6aaS99®(.A� BUSINESS PHONE <br /> 7 if bn rhe li-�- ` (JI Sufte# 7 l S�3I <br /> CITY(N FACa/n'6 a MOBLEFow UML, or FooD,Vri9aE use the[=�r-:_ae<eeY rrm $TATS <br /> /` 5 <br /> fy ZIP C- 237 <br /> BOARD OF SUPEILRVISSUPERVISORDDIIISSTRICTVLO,FIFA LOCATION CODE KEY1 KEY2 <br /> ARtUG ADDRESS for Health Perrnit(if DIFFERENT from Facify,Address) Attention or Care Of <br /> {Y[ U ` <br /> MAILING ADDRESS CITYIl $ ATE ZIP L�c.�-177 <br /> SIC CME: � APN#: 0 CamtENr: JJ o�.J <br /> ACC(WINTADDRESS-for fees and charges: OWNER ❑ FACiLITYIBUSINESS ❑ <br /> BnJJNO AND Compi.rANCE ACKNOWI.FDOMFNT: 1, the undersigned Applicant, certify that I am the Owner, Operator, or Authorized Agent of this <br /> Business,and I acknowledge that all PExm4r FEES,PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation will be <br /> billed to me at the address identified above as the AccorwTADDRecc for this site. 1 also certify that all information provided on this application is true and <br /> correct; and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards <br /> and STATE and/or FEDERAL,Laws and Re ulations. <br /> APPLICANT NAME: :)-I SIGNATURE: <br /> Please Pnnt <br /> TITLE: DATE DRNER's LICENSE# <br /> Approved By DateLA Accounting Office Processing Completed By ( Date 1 <br /> 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 I OCATION except <br /> UST Program(Use SWRCB forms) <br /> EHD 48-02-035 Masterfile Record-Green <br /> 10/9/2003 <br />