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SAN .JOA N COUNTY ENVIRONMENTAL HEALTH D PARTMENT <br /> STERFILE RECORD INFORMATION F <br /> SHADED SECTIONS FOR EHD USE ONLY OWNER ID# 7 CASE# <br /> / „ �U� ` J <br /> OWNER FILE <br /> COMPLETE THEFOLLOW/NG BUSINESS OWNER INFORMATION. CHECK IF OWNER CURRENTLY ON FILE w1rHEHD❑ <br /> BUSINESS W. -�5Q/yJQs PHONE: <br /> OWNER'S NAME rrry <br /> First MI Last <br /> BUSINESS NAME(H different from Owner Name) SOC Sao or Tax ID# <br /> m <br /> OWNER'S HOME ADDRESS 1,2 GJ11 M <br /> CIN (Ah CA STATE zip q�-1 L/O <br /> OWNER'SMAILINGADDRESS (if diRerent from Owner's Address) Attention orCare of L• <br /> MAILING ADDRESS CITY STATE zip <br /> TYPE OF OWNERSHIP: <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY OTHER❑ <br /> FACILITY FILE <br /> FAclurYlD#: A 0 y �3 � s CO-OWNERID#: ACCOUNT ID <br /> COMPLETE THE FOLLOWING BUSINESS FACILITY INFORMATION., <br /> [18 NS a NEW BUslness LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES NO this aNEWs this an E%ISTING BUsInBS3 LOCATION bili a NEW TYPE of regulated Business? YES ❑ NO Nt <br /> BUSINESS/FACILITY NAME(This will be the BUSINESS NAtreon the HEALTH PERMIT) <br /> ede <br /> FAOILITYADDRESS(HFA /LITrlea MOBILEF000 UNiror FOODVEHic uee the COMMISSARY ADORES SJ BUSINESS PHONE <br /> Ia5i1 Murry Lf-I a q -2 a,?J <br /> Suite# <br /> CITY(If FAcit."iS a MOBILEFOOD UNIT or FOOD VEHICLENSe the COMMISSARYCITY) STATE zip <br /> ZIP Vo <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> MAILING ADDRESS for Health Permtf(H DIFFERENTfrom Facility Address) Attention orCare Of <br /> MAILING ADDRESS CITY STATE ZIP <br /> SIC CODE: APN#: \/ ^ COMMENT: <br /> _n^ ..Jf.. V It <br /> ACCOUNTADDRESS for fees and charges: OWNER ❑ FACILITY/BUSINESS ❑ <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and <br /> I acknowledge that all PERMIT FEES,PENALTIES,ENFORCEMENT CHARGES and/Or HOURLY CHARGES associated with this Operation will be billed t0 me at the <br /> 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 <br /> all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or <br /> FEDERAL Laws and Regulations. <br /> APPLICANT'S NAME: SIGNATURE: <br /> Please Prinf <br /> TITLE: DATE DRIVER'S LICENSE# <br /> PHOTOCOPY REQUIRED <br /> Approved By Data Accourding OFice Proceeeing Completed By "]/' � Date 1/2 1 ZI l <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 LOCATION <br /> except UST Program(Use SWRCB forms) <br /> EHD 48-02-035 Masterfile Record-Green <br /> 8H 9108 <br />