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t , SHADED SECTIONS FOR EHD USE ONLY SAN JOAAN COUNTY ENVIRONMENTAL HEALTH' ARTMENT WSTERFILE RECORD INFORMATION F l�vt OWNERID# Ip/ n .�/t.-2 CASE# OWNER FILE COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION: CHECKIF OWNER CURRENTLYON FILE WITH EHDI BUSINESS OWNER'S NAME r ( PHONE: first MI I Last BUSINESS NAME (If diNemnthom OwnerName) U S — 2 , -f;a 4/� A SOC SCC Or Tax ID # OWNER'S HOME ADDRESS CI Ave— .ve— CITY CITY � / Gi a STAT ZIP S `?-5OWNER'S MAILING ADDRESS (If diferentfmm Owners Address) L" Attention orCare of O a_�_ CZi MAILING ADDRESS CITY STATE ZIP s� TYPE OF OWNERSHIP: CORPORATION ❑ INDIVIDUAL PARTNERSHIP LOCAL AGENCY ❑ COUNTY AGENCY ❑ STATE AGENCY ❑ FED AGENCY ❑ OTHER ❑ FACILITY FILE FACILITY ID#:. - CO-OWNER ID#; ACCOUNT ID#: $1 COMPLETE THE FOLLOWING BUSINESS FACILITY INFORMATION: Is this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES *IR NO ❑ Is this an ExISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ NO ❑ BUSINESS/FACILITY NAME (8115 will be the BosINESSNAmzon the HEALTH PERMIT) `�- � l'ill 'J w.t�. FAciL/iTy ADDRESS (If FAcnmis a Mbai eFa Uwrror I/EHrrlEgse the Commis RYAooBEss) 4q; b q Dire eNfNOame� T a S'StreetN BUSINESS PHONE 2t�9) 43J-/ff ?r CITY (if FAuums a MOBILE FOOD UNIT or FOOD VEwcLe use the CommissA yC1TYl S�tha_ STATE � ZIP �jS2lS BOARD OF SUPERVISOR DISTRICT LOCATION CODE ! KEY1 KEYZ MAILING ADDRESS far Health Permit(If DIFFERENTfrom Fad/ityAddres) Attention orCare Of MAILING ADDRESS CITY STATE zip $IC CODE: APN#: e432 %-c22_Ld COMMENT: AC220 TADDRESS for fees and charges: OWNER ❑ FACILITYIBUSINESS BILLING AND COMPLIANCE ACKNOWLEDGMENT: ],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/of 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 Requlations. APPLICANT's NAME: �� ;.0 q ( C4 (� SIGNATURE: Please Pnnt TITLE: DATE DRIVER'S LICENSE # PHOTOCOPY REQUIRED) Approved By Oate Accounting Office Processing Completed By Date 11_ / /y !✓ u l 77 'J 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) EHD 48-02-035 MasterFlle Record -Green 8/19/08