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i. <br />SHADED SECTIONS FOR EHD USE ONLY <br />SAN .JOAI COUNTY ENVIRONMENTAL HEALTH ( RTMENT <br />1`MSTERFILE RECORD INFORMATION FO <br />OWNER ID # CASE # <br />OWNER FILE n <br />.. r IAILICO Ivrno✓wwrnwr CHFr:K IF OWNFR CURRENTLY ON FILE WITH EHDI I <br />t.VMt Lcic Inc rVLLV✓vaYV <br />ollauY�ou vYnYu� u <br />SS/FA ILITY NAME (This will be the B sl 5 NAMEp6}tLe HEALTH PERMIT) <br />S , <br />- - <br />PH NE ,1 <br />Last �� <br />BUSINESS-- <br />OWNER NAME <br />First <br />MI <br />BUSINESS NAME (If Ui ferent from Owner Name) <br />G evi N4l44C <br />SOCc Or Tax ID # <br />s <br />HOME ADDRESS Q e1tS9h4 V <br />SUPERVISOR DISTRICT <br />[OWNER <br />Cm Ll <br />KEV1 <br />STATE <br />ZIP <br />OWNER MAILING ADDRESS (If diBar6nt from Owner Address) <br />ADDRESS for Health Permit(If DIFFERENTfrom FwRyAddress) <br />Attention or Care of <br />MAILING ADDRESS CITY <br />ADDRESS CITYSTATE <br />STATE <br />ZIP <br />TYPE OF OWNERSHIP: <br />CORPORATION❑ INDIVIDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY FED AGENCY El OTHER❑ <br />FACILITY FILE <br />FACILITY ID #: CO-OWNER ID #: ACCOUNT ID #: <br />I✓ICcc rwnll ITV Iuf_llouwrinwl• <br />LiUMYLCIC /r1C rVLLVYYIIYV OVJII\G I"I-IVIuI I <br />NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES. <br />n EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No� <br />NO ❑ <br />SS/FA ILITY NAME (This will be the B sl 5 NAMEp6}tLe HEALTH PERMIT) <br />Y ADDRE SI f&OUlYISa ILE FOOD UNrror FOOD VEMCLE use the rb^'ccnRY ADDEESS <br />C 1 1 W <br />Suite # <br />BUSINESS PHONE <br />FINEF'A <br />FAdLrrvK Mo'LeFOOD UMror FboD VEwDLE use the rnuurcceRYrm) <br />O <br />SAiF,C <br />r- 11AF <br />SUPERVISOR DISTRICT <br />LOCATION CODE <br />KEV1 <br />KEv2 <br />ADDRESS for Health Permit(If DIFFERENTfrom FwRyAddress) <br />Attention or Care Of <br />ADDRESS CITYSTATE <br />ZIP <br />E: <br />APN #: <br />CouMEM: <br />ArrniINT AnnRPRC for fees and charges: OWNER ❑ <br />tcx <br />FACILITY/BUSINESS IC7 <br />BILLING INC AND COMPI IANC F ACKNUMMEDGMPNT: I, the undersigned Applicant, certify that I am the Owner, Operator, or Authorized Agent of this <br />Business, and I acknowledge that all PERMIT FEES, PENALTIES, ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation will be <br />billed to me at the address identified above as the AA rnr�AnuRR.cc for this site. I also certify that all information provided on this application is true and <br />correct; and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards <br />TITLE: <br />n I <br />DATE <br />Approved By 6�, ®32_- / I Date 7 / i I ( 0�;— I Accounting Office Processing Completed By I Date <br />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 I OCATION except <br />UST Program (Use SWRCB forms) <br />EHD 48-02-035 71ti tar— V Masterfile Record -Green <br />10/9/2003 'ja� �. y�,�`'t oC �-F ✓r d� gyri <br />