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yt SAN JOAQUIN COU PUBLIC HEALTH SERVICES 4, ENVIRI ENTAL HEALTH DIVFSION <br /> FORM (EH OO15(REVISED101021961 <br /> DATE ILMAI I96 MASTERFILE RECORD INFORMATION <br /> ........... <br /> SH4DED SECT70NS FoR EHD UsE CM V ::OWNEIC ICY S: !T -C 7 <br /> OWNER FILE <br /> COMPLETE THE FOLL owiNG BUSINESS OWNER lwoRmA TION: CHEcKiF OWNER CuRReN7EyoNrxEwjTHEHD El <br /> .......................-........*.......................... 1-1............................................................................................................................................................................................... <br /> BUSINESS OWNER PHONE <br /> NAMEL-----------------—---—-------------------- <br /> ................................. .............................................. <br /> BUSINESS SOC SEC!TAX I0* <br /> OWNER HOME ADDRESS DRIVER'S LICENSE# <br /> STATE zip <br /> city <br /> Attention:orCare of(apfidnal) <br /> DRESS WOIFFERENT from OwnerAddress <br /> OWNER HARINGAD <br /> AM H 702,44AIKI <br /> Mailing Address City Stabe i zip <br /> 0C/ <br /> TYPE OF OWNERSHIP: <br /> CORPORATION INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY 0 COUNTY AGENCY 0 STATE AGENCY 0 FED AGENCY ED OTHER 0 <br /> FACILITY FILE <br /> ......... . <br /> ........1- . ..... ACCOUNT 10i <br /> Wo ROStiRIEF.' ................... <br /> 7 7 <br /> FACILITY.Ip ...... 7 <br /> COMPLETE THEFOLLOWING BUSINESS FACILITY INFORMATION. <br /> Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DivisioN? YES No El <br /> Is this an EMSTING Business LocATiON but a NEW TYPE of regulated Business? YES ❑ No <br /> Busimess/FAcILITY NAME(TmswiLL BE THE NAME ON HEALTH PERMIT) <br /> FAciuTyAoDRESS(IFFAciLiTYISAMosiL.EFooDUAYToRFooDVzpwLEUsECOMUSSARY AOORESSI SUITE 9 BUSINESS PHONE <br /> L� A-4wy- <br /> h�t&� y <br /> CITY IF FA CIU Tr I$A MoBiL e FboD Um r oR Fdoi 2 VE mcL E usEpo m�Mi ss:An Y A�DD R ES s�C i STATE zip <br /> ....... ....-.7771 <br /> .......... <br /> Mailing Address for Health Permit iFD1FFEREAfffwmFadfi1yAddrass Attention:or Care Of(apbbmi) <br /> Mailing Address City STATE ZIP <br /> .......... <br /> ........... <br /> ........................ <br /> -77 <br /> THIRD PARTY BILLING INFORMATION: Complete if Billing Party is different from Business Owner Identified above. <br /> ............ .......................................I...................................................... .......... ................. ........................................................................................................... <br /> BUST s NAME Atte on:or Care Of(opfibrial) <br /> Mailing Ad)n�. <br /> CITY <br /> s 0"o \L2� <br /> ACCOUNT ADDRESS for fees and charges OWNERX FACIUTY/13USINESS El THIRD PARTY BILLING ❑ <br /> I - <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Owner, Operator, or Authorized <br /> Agent of this Business, and I acknowledge that all PERMIT FEES, PENALTIES, ENFORCEMENT CHARGES and/or HOURLY CHARGES <br /> associated with this operation will be billed to me at the address identified above as the AcCOUNTADDRESS 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. PLEASE PRINT <br /> APPLICANT NAME?rl-K &4 SIGNATURE( <br /> TITLE DRIVER'S LICENSE <br /> (PHOTOCOPY REQUIRED) <br /> 777777777777] <br /> ij . <br /> pprov!*d flats <br /> WA............... <br />