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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH D _PARTMENT OSTERFILE RECORD INFORMATION FOA SHADED SECnONs FDREHD USE ONLY OWNER IDCASE# OWNER FILE COMPLETE THE FOLLOw1NG BUSINESS OWNER INFORMATION: CHECKIF OWNER CURRENTLY ON FILE wiTH EHD❑ BUSINESS PHONE: OWNER'S NAME First MI Last BUSINESS NAME(If different from Owner Name) Soo Sec or Tax ID# OWNER'S HOME ADDRESS CITY STATE zip OWNER'S MAILING ADDRESS (If different from Owner's Address) Attention or Care of MAILING ADDRESS CITY STATE zip TYPE OF OWNERSHIP: CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY OTHER❑ FACILITY FILE FACIDTYID#: ODZZSbZCO-OWNER ID#: ACCOUNT ID#: Q� COMPLETE THE FOLLOw/NG BUSINESS FACILITY INFORMATION: IS this a NEW Busina33 LOCATION or VEHICLE AOL previously regulated by the ENVIRONMENTAL HEALTH YES ❑ NO n._,..r....�.,.o IS this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ NO BUSINESS/FACILITY NAME(This will be the BuslNEss Naueon the HEALTH PERMIT) (✓Lv �J.,f((', ZnL, FACILITY ADDRESS(If FACILITY is a MOBILE F000 UNITor FOOD VEHIctEuse the COMMISSARY ADDRESS I BUSINESS PHONE I ea Ffa4k �I�t C: r. 10h-*)--0760 Suite# CITY(If FACILITra a MoaaEF000 UNIT or FOOD VEHICLE use the COMMISSARY CITY I STATE zip +00<+9n (P BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEYf KEY2 MAILING ADDRESS for Health Permit(If DIFFERENTfrom Facility Address) Attendon or Care Of MAILING ADDRESS CITY STATE zip SIC CODE: APN#: COMMENT: ACCOUNT ADDRESS for fees and charges: OWNER ❑ FACILITY/BUSINESS L� 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 ACCOUNTADDRESS for this site. 1 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: SIGNATURE: Please Print TITLE: DATE DRIVER'S LICENSE# PHOTOCOPY REQUIRED Approved By Date AccountIng Office Procesaing Completed By Date 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 LOCATION except UST Program(Use SWRCB forms) EHD48-02-035 � D MasterMasterfile Record-Green It'. 8119108 IJ t%vz creC -IuC 1'F��--�tJ I �,.cu,-ttve &.AA bm -3iVtib(e I ` I'^ �(AOG