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SAN JOAQI COUNTY ENVIRONMENTAL HEALTH Dr--1RTMENT r 11hr,STERFILE RELORD INFORMATION FOR,, SHADED SECTIONS FOR EHD USE ONLY OWNER ID# DO� -7 I CASE# OWNER FILE COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION: CHECK IF OWNER CURRENTLY ON FILE WITH EHD BUSINESS �� /�� I L ) f< CS �j{]✓3f}�j_ J� l- (PHONE OWNER NAME First MI Cast BUSINESS NAME(If different from Owner Name) TSocSeicor Tax ID# OWNER HOME ADDRESS // A 577 3 / G y-� i�4C <is Jj CITY c• STATE, ZIP `] 7 OWNER MAILING ADDRESS (If different from Owner Address) Attention or Care of MAILING ADDRESS CITY STATE ZIP TYPE OF OWNERSHIP: CORPORATION EF INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ FACILITY FILE Q FACILITY ID#: C) I�I�--7 CO-OWNER ID#: ACCOUNT ID#: ( /k COMPLETE THE FOLLOWING BUSINESS FACILITY INFORMATION: IS this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES NO ❑ IS this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ No BUSINESS/FACILITYNAME(This will be the BusiNEss NAME on the HEALTH PERMIT) �s' 4-41—j FACILITY ADDRESS(If FACILITY is a MOBILE FOOD UNIT or FOOD VEHICLE use the COMMISSARY ADDRFSS) BUSINESS PHONE Street Number Direction Street Name re Type Suite# CITY(If FACILITY is a MOBILEFOoD UNrror FOOD VEHICLE use the r:nMMLesARY r:m) STATE ZIP BOARD OF SUPERVIsm DISTRICT Dv S LOCATION CODE ��}G- KEY1 KEY2 MAILING ADDRESS for Health Permit(If DIFFERENT from FacilityAddress) Attention or Care Of MAILING ADDRESS CITY STATE ZIP SIC CODE: APN#: 2-32-Z']Q j COMMENT: dr_rnuNT AnnRFSS for fees and charges: OWNER ❑ FACILITY/BUSINESS Bui,I,ING AND Compil IANCE ACKNr)wunGMRNT: I, 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/or H014RLY CHARGES associated with this operation will be billed to me at the address identified above,as the ACCOIINTAnDRFsr 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 Re ulations. >�172 G. L, ,�'. G t 17?. APPLICANT NAME: SIGNATURE: y� Please Print TITLE: / �S!/�L=1✓T— DATE /rj,){� DRIVER'S LICENSE# (PHOTOCOPY REQUIREDI Approved By Cj (// Date Accounting Office Processing Completed By Date �/)yl C J A PROGRAM{EHD 48-02-034 Pink)or WATER SYSTEM{EHD 46-02-003)form must be completed for ea>;h EHD regulated operation at this LOCATION except UST Program(Use SWRCB forms) EHD 48-02-035 Masterfile Record-Green 10/9/2003