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SAN JOAQUIN COUNTY e•BLIC HEALTH SERVICES ♦ ENVIRONML HEALTH DIVISION <br /> FORM (EH0016(REVISEDIO/811961 <br /> DATE j— MASTERFILE RECORD INFORMATION , / D� ^ f <br /> SHADED SECRONS FOR EHD USE OWLY OWNER ID R'. UU DU (J. y GA9Ei U <br /> OWNER FILE <br /> COMPLETE THEFOLLOWINGBUSINESSOWNER INFORMATION. C//ECRIFOWNER CURRENnYON FILE wirtIEHD <br /> ................................................................................................................................................................................................................................. <br /> I BUSINESS OWNER i j PHONE 1 <br /> 1 <br /> NAME <br /> t..................................................................F,,;r----...... n----------rsr---------i X9- '21, 7- b 7// <br /> . ........................................................................................................ <br /> .............................. <br /> i BuslNEse NAME n(If d///ercnt/rom Owner Name) <br /> SOC SEC/TAM ID/ i <br /> OWNER HOME ADwtEee Ll <br /> �S% !ii 4T'117- <br /> I i City STATr A; j ZIP /1 i <br /> L F j L/S20Z I <br /> i OWNER MAILING ADDRESS ND/FFEREAfrtmm OwnerAddrase I Attention:or Care of (optional/ I <br /> Mailing Addreas City i Stale i Zip <br /> TYPE OF OWNERSHIP' <br /> CORPORATION El INDIVIDUAL PARTNERSHIP El LOCAL AGENCY L1 COUNTY AGENCY 11 STATE AGENCY El FED AGENCY L1 17TI1ER❑ <br /> FACILITY FILE <br /> FACILITY ID III C)0 1 / GRGsd:R ID <br /> COMPLETETHE.FOLLOW/NG BUSINESS FACILITY INFORMATION: <br /> Is this a New Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DIVISION 7 YES NO ❑ <br /> Is this an OUSTING Business LOCATION but a NEW TYPE Of regUlaled Business 7 YES ❑ No ❑ <br /> BusINE1alFAmuTY NAME(THIS WILL RE THE NAME ON HEALTH PER MIT) <br /> �/�/��JG%i� TSO rn-I' ��C AGL.�(?lAl� �< �}1— ,�•/I1f�—.fLOwV j <br /> FACILITY ADDRESS#F FACturY/S A MOBILE FOOD UmroR FOOD VELYCLE USE COMMISSAR OORESS I SUITED j BUSINESS PHONE <br /> i GTY/F FACIL/rY/SAMOB/LEFOOD UNTOR FOOD VEHICLE USE YALIONESS CITY) STSTATE <br /> ZIP /Z : <br /> 7 : <br /> BOARD CW BIRERY160N DISTRICT-- LOdAT10N COQE :- N KEYZ' <br /> I Malting Address for lfedlth Permit NOIFFERENr"mFacl/ItyAddr&m i Attention:or Care Of lopUonal) <br /> Mailing Address City STATE ZIP <br /> : I <br /> tic QODE !' APNIf t COMMENT <br /> THIRD.PARTY.BILLING INFORMATION: CoMplete if Billing Party Is different from Business Owner Identified above. <br /> . <br /> ......... . ...... <br /> .......... <br /> I.............. ... . .................. . . .................. ... .. <br /> Buswess NAME ((�� Al)Bdlgn:or Care Ol (op�ga/J <br /> 1 !3 rv�✓� �46 <br /> 1 Malling Address i PHONE 1 <br /> 2o6?- 63gis- <br /> � CITY <br /> T; i <br /> Sr 1 zIP'N ZOI�C// <br /> Ar=UNTADDRESS for fees and charges OWNER ❑ FACILITY/BUSINESS ❑ THIRD PARTY BILLING I� , <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I, the undersigned Applicant, certify that I am the Owner, Operator, or Authorized <br /> Agent of (kis Business, and I acknowledge that all PERMIT FEES, PENALTIES, ENFDRCESIENT CHARGES and/or HOURLY CHARGES <br /> associated With this operation will be billed to meat the address identified above as the ACCGUNTADDRFSS for this site. I also certify <br /> that all information provided on this application is true and correct; and that all regulated activities will be performed in <br /> accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or FEDERAL Laws and <br /> Regulations. <br /> � PLEASE PRINT <br /> APPLICANT NAME TQ VYl 1c§-X( �P Ir L f� SIGNATURE <br /> TITLE '^C/ DRIVER'S LICENSE M <br /> A— �-~��t �D I S � _ (PHOTOCOPY REQUIRED) <br /> Approved By IDala Accounting pRICa Proaaesing Gomplalad Gy'. f Dale ll`�lG c <br />