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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT kSTERFILE RECORD INFORMATION FO ` SHADED SECTIONS FOR EHD USE ONLY OWNER ID# )WOO VZO CASE# OWNER FILE COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION: CHECK/F OWNER CVRRENrLrONFXEwiTNEHD❑ BUSINESS 1A E� �/ = PHONE: OWNER'S NAME 8'K Frst MI Last '1 BUSINESS NAME(If WRemnr Nom Owner Name) Soc SBC orTax ID 13 ' s shop OWNER'S HOME ADDRESS �n l^� (�(��. CITY Sr0L 0 ✓ �,-� STA ZIPq 5 OWNER'S MAILING ADDRESS (H diFerentfro Ownees Address) Attention Ix-Care of '� MAILING ADDRESS CITY $TATE ZIP TYPE OF OWNERSHIP: CORPORATION❑ INDIVIDU PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY OTHER❑ FACILITY FILE FACILITY ID#: Q S CO-OWNER ID#: ACCOUNT ID COMPLETE THEFOLLOHONG BUSINESS FACILITY INFORMATION: IS this a NEW BUSlness LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES F1 No C]nee.orucurr IS this an E%ISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ NO ❑ BUSINESS/FACILTfY NAME(This will be a BUSINESS AIthe HEALTH PERMIT) it`I e r FACILITY ADDRESS(If FAaurris a MOamEFDODUM or FOOD VEHiCt x the CoMMIssARY ADDRESS) lA, �,�- BUSINESSPHONE Igo-7- 5 . C�Pr� �— �� 3u4ek y DAY CITY(If FACILT'S a MOBLE F60D UNIT Or FOOD VEHICLE use the COMMISSARY CITY) 1 II STATE(A P BOARD OF SUPERVISOR DISTRICT LOCATION CODE /`TIyKEE1DYY111 /// KEY2 MAILING ADDRESS fOFHeaIII7 Permd(If D/FFERENTfrom Faci11tvAddrel ss) Attention wCare Of MAILING ADDRESS CITY STATE ZIP SIC CODE: APNP BIW (✓ COMMENT: ACCOUNTAODRESS 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 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. A64LICANT'S NAME: (,//LZ-IX,/', A;s�-��'L SIGN TORE: 11-1 PARRS&Pnnt TITLE:/T - pTE�� j DRIVER'S COPYR PHOTOCOPY REQUIRED) APPreve4 BY l Date GC O„ 2 Aae eu ns Mee Proeaui,p Cdnple BY Dete f\ A PRcx RAI*(E D 2 Pink)or WATER SYSTEM(EHD 4602A 111*1unn rmtsFbe completed for each EHD regulated operation at this LOCATION, except UST Program(Use SWRCB forms) EHD 48-02-035 Masterfile Record-Green 8119108