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SAN JOAQUIN COUNTY ENVIRONMENTAL HT 0��O 1�PARTMENZ MASTERFILE RECORD INFORMA • CASE# ' OWNER ID# C/ WDD SHADED SECTIONS FOR EHD USE ONLY OWNER FILE CNI=CI:IF OWNER CURRfNrL!'ON FILE WITH EMD❑ r ATION' PHONE: CORfPLETETHFfOLLOtRIIArGE�USiNI=SS 11 iOErif`F�EER INFORMATION'. C'O �0 +I t17'S t 0 BUSINESS t�U�-t C1 l.�l� l Eli, Last 11 MI Soc Sec 0 ax ID OWNER'S NAMr- First BUSINESS I\EANIE(If different from2��i✓{��s v s � uJ a� �c o zip $pAT 9�z OWNER'S HOME ADDRESS l CITY ��0 I Attention arGare of OWNER'S MAILING ADDRESS (If different fromOwner's Address) STATE SIP IVIAIL,NG ADDRESS CITY TYPE0F OWNERSHIP: COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY OTHER❑ CORPORATION❑ INDIVIDUAL[I PARTNERSHIP LOCAL AGENCY❑ FAMITY FILE ACCOUNT ID �0�3�! CO-OWNER ID#: FACILITY lD#: 1 COfi,PLETETHE FOLLOWING BUSI MESS FACILITY INFORMA-17f3A`. YES d No ❑ Is this a NEw Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEAL No nrn��-• _- regulated Business? Is this an EXISTING Business LOCATION but a NEW TYPE of V1Vt�� 2�C SY�2 BUSINESSIFACI�NAME(This will be the 8usrxEss�NGE�Eon the HEALTH PERMIT) Z f arrsisseaY ADORES7I UO BUSINESS PHONE FACILITY to (If yFA'CILLm is a/1�fOajutf�FOOD UNITor FOOD VEH=Euse the L 1 `o W, V! `1" S I ST Su A zip 77 7 CITY(If FACrurYls a hf0nrL1 Fovn Urrrror Foon VEHICLE use the Co•.:'+i55�FY Crr 1 )Q LOCATION CODE KEY1 KEY2 T BOARD OF SUPERVISOR DISTRIC Attention orCere Of MAILING ADDRESS for Healm PerMff(If DIFFERENrfrom FacilrtyAdr� � /QU�� rZ �d ii,>•/!A cSTAj2,4— 7JP C� MAILING ADDRESS CITY �� I APN#: COMMENT: SIC Cooe: ACCOUALA DO ESS far fees and charges: OWNER ❑ FACILITYIBUSINE _� _ BILLING AND COMPLIANCE ACKNQWLEDGMENT: I,the undersigned Applicant,certify that 1 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 ACCOUNTAODRESS 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 JOAouIN COUNTY Ordinance Codes anchor stanaaras a�,a sz:.zc a„a,c� FEDERAL Laws and Regulations. APPLIGANT'S NAME; � �� SIGNATURE: :�� �` f Please Print DATE I/ Z��✓TITLE: PHOTOCOPY REQUIRED) 3� /Z� f� Approvod ay a to t?eta I I f/ TA office Procesafng comprcted By / Deto /�3 A PROGRAM{EHD 4-02-034 Pink}or WATER SYSTEM{EHD 46-02-0031 form must be completed for each EHD regulated operation at this LOCATION except UST Program(Use SWRCl3 forms) EHD 48-02-035 Masterfile Record-Green 8119t08