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SANJOA COUNTY ENVIRONMENTAL HEALTH D RTMENT TERFILE RECORD INFORMATION FORD SHADED SECRONS FOR EHD USE ONLY OWNER ID III D IA] bD " CASE III OWNER FILE FIILuE40 COMPLETE THE FOLLOWING BUSINESS OW N ER INFORMATION. CHECK IF OWNER CuRReNTLYON FILE wiTH EH DO BUSINESS1 ��`S PHONE: OWNER's NAME J ` Bg.•� First MI Last BUSINESS NAME(If diNerentfrom,Owner Name) � OWNER'S HOME ADDRESS 6763 U'iCkS t1,r �L CITY S O 'I t7✓� S?,* OWNER'S MAILING ADDRESS (If ditferentfrom Owner's Address) Attention arcane of MAILING ADDRESS CITY STATE ZIP TYPE OF OWNERSHIP: CORPORATION❑ INDIVIDUAL, . PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FEDAGENCY OTHER❑ FACILITY FILE FACILITYID#: CO-OWNER ID#: ACCOUNTID#: COMPLETETHEFOLLOW/NG BUSINESS FACILITY INFORMATION: Tt�hlsNEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES NO E%ISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ NO BUSINESS/FACILITY NAME(This will be the BUSINESS NANEon the HEALTH PERMIT) FACILITY ADDRESS(If FAC/L/rri9 a Moa2EFoon,6Wnor FOOD VEHIcLEuse the COMMISSARY ADDRESS) BUSINESS PHONE 15-)3 £ ChltalccF = suite# �)o ` loL—')SO,' CITY(If FAuLRYIspp MOBILE FOOD UNIT Or FOOD VEHICLE use the COMMISSARY CIN) STATE ZIP 5f e kfo � Fsdos— BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 MAILING ADDRESS for Health Perm t(If D/ FE ENTfrom FactRyAddress) Attention orCare Of 70 V k��u v+ L MAILING ADDRESS CINSTAT /j ZIP C;t�Q I SIC CODE: APN#: COMMENr: ACCOUNTAa ESS for fees and charges: OW ER FACILITY/BUSINESS11 ❑ BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that 1 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 t0 me at the address identified above as the ACCOUNTADORESS 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. APPLICANT'S NAME: JF 1 V q rJ ✓'✓'S SIGNATURE: Please Print TITLE: to f DATE /'�9 DRIVER'S LICE E# PHOTOCOPY Approved By Date j- Accounting Office Proeseeing Completed By Deb 1 A PROGRAM(EHD 48-02-034 Pink)or WATER SYSTEM(EHD 48-02-003)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