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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ASTERFIL&RECORD INFORMATION FG , w yzloK SHADED SECTIONS FOR EHD USE ONLY OWNER ID# I L CASE# OWNER FILE COMPLETE THE FOL LOW/NG BUSINESS OWNER /NFORMAT/ON: CHECKiF OWNER CURRENTLYONFILEwiTHEHD❑ BUSINESS `` ,, PHONE: OWNER'S NAME lv First MIS Las BUSINESS NAME(If different from Owner Name) Soc Sec or Tax ID# OWNER'S HOME ADDRESS CITY ST T ZIP i OWNER'S MAILING ADDRESS (if different from Owner's Address) Attention orCare of MAILING ADDRESS CITY STATE ZIP TYPE OF OWNERSHIP: CORPORATION❑ INDIVIDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY OTHER❑ FACILITY FILE y FACILITY ID#: ,%�Qt) j CO-OWNER ID#: ACCOUNT ID#: i} 10 COMPLETETHEFOLLOw1NGBUSINESS FACILITY/NFORMAT/ON.' IS this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES NO ❑ nO C-7 Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No BUSINESS/FACILITY NAME(This will be the BuswEssNAmEon the HEALTH PERMIT) FACILITY ADDRESS(If FACILITYIs a MOBILEFOOD UNlror FOOD VEHIctEUse the COMMISSARY ADDRESS) PUSINESS PHONE Direction a "eel T e Suite# 3 I CITY(If FACILITY is a MOBILE FOOD UNIT Or FOOD VEHICLE use the COMMISSARY CITY) STATE I P q,t� BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 MAILING ADDRESS for Health Permft(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 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. ll 'F APPLICANT'S NAME: `PN 0SIGNATURE' Please Print TITLE: DATE DRIVER'S LICENSE# PHOTOCOPY REQUIRED Approved By Date Accounting Office Processing Completed By Date 7 A PROGRAM{EHD 48-02-034 Pink}or WATER SYSTEM{EHD 46-02-041;form must be completed for each EHD regyla operation at this LOCATION except UST Program(Use SWRCB forms) EHD 48-02-035 Masterfile Record-Green 8119108