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SAN JOAQUIN COUNTY • PULILIG HL-AL7H SLHVIGL6 • ENVIRONMENfAL HEALTH DIVISION '� 9 -� — — — - -- - - — - ----——-- --- FORM (EH 0015(REvisED 70131196) DATE ,.,ASTEfiFILE RECORD INFORMATION stiAOFD SECrloNs FOR EHD USE OAII Y OWNER ID 0 CASE IY OWNER FILE COMPLETETHEFOLLOW/NG BUSINESS OWNER INFORMATION: Cirtaxif OWNER CuuRtNliroNi1jtwj1[iEHD .............................................................................................................................................1111........................... ............................. ..... ............ ............... BUSINESSOWNLR PIIoNE �(`• L. II�/, 11Gq CV�, j I NAME --------F --------- T----------- - -------- -3 � i .................................................................................................................................................... i BusimEss NAME(if diffo�reni�t from Owner Namol` `� 1` S/x;Stc I TAx ID If P�Cyfl�SISi� Scr`loQ� yS L OWNER HOME ADDRESS City s1AlE ZIP -3 OWNER MAILING ADDRESS NO)FFERENT h'om Owner Address i Attention:or Care of (optional) i Mailing Address City Stale ZIP TYPE OF OWNERSHIP: I CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY COUNTY AGENCY❑ STATE AGENCY F1 FED AGENCY❑ OTHER❑ FACILITY FILE -71 FACILITY ID if Uqto CROSS REF ID IV IT ACCOUNT ID Ii COMPLETETHE.FOLLOW/NG BUSINESS FACILITY INFORMATION: �/ Is this a NEIN Business LOCATION or VEHICLE not Previously regulated by the ENVIRONMENTAL HEALTH DIVISION 7 YES-O NO ❑ Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business 7 YES ❑ No E BuslNEss/Fwcu.ITr NAME(Tins WILL BE THE NAME ON HEALTH PERMIT) C f'<s T FACILITY ADDRESS(IF FAcILgY15A MOBILE F000 UNIT oR F000 V&NcLE UsECOMMIsSARYAIp)Rt SS) 3 SUI IES BUSINESS PHONE Cm1FFAcwTYISAMoetLEF000 UN/reRF000 VEIMOLEusECONMIsMPYADIHAL§s C11Y) Slwj� ` ZIP BOARDOF SUPERVISOR DISTRICT LOCATION CODL' KEY1 11_KEY2 i Mailing Address forl/eatth Permit ifDIFFEREM)"from FAci/ityAddress i Attention:or Care Of(optional) i Mailing Address City STATE i ZIP SIC CODE APN* COMMENT -- - 1 THIRD PARTY BILLING INFORMATION: Complete if Billing Party is different from Business Owner Identified above. _........................................................................................... . BUSINESS NAME � r ( w l� i Attention:or Caro Of (optional) i Mailing Address r ,� u PHONE �-Z0Oi 1 �S3CITY SIAn: A- ZIP ACCQUNTADDRESs for fees and charges OWNER FACILITY/BUSINESS ❑ THIRD PARTY BILLINGEl BiLLINC AND COMPLIANCie,ACKNOWLE'l)GAIENT: 1, the 111)(1 -Signe(I AI)I)lic11nf, certify flat I am file fhv/ter, f)perulor, or Authorized Agent of this Business, and I acluurlvledge til:It Al PhRART P'E'ES, Ph_w,11.7'If.s, ENhY/1t(-'L'.11h'N1' 01ARGE'S 111)(1/01- HOURLY CHARGES associated with this operation will Ile billed to Ale at the address identified above 11s the ACCOIIN7'ADDRh_"SS for this site. I luso certify that all information provided on this application is true and correct; and that all regulated activities will be performed in accordance with all :lpplicablC SAN JOAQUIN COUNTY 0l'tli1lallee Coes and/or Standards and STATE and/or FIG)FRAI. L:nrs :uul RCgulationS. PLEASE PLAINT APPLICANT NAGE_ �I e n/�/ /�Zy�� SIGNATURE TITLE nWY�+L�L-liL DRIVER'S LICENSE)) ,58- J�WqY► (PIIOIOCOPY REOl11NF.11) rI�LkJ Q Approved sy Oat a Asoountblp Off Q11 Preu#)aslna GomAlytvd oaty 7 13 N X