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SAN JOAQUIN COUNTY • PUBLIC HEALTH SERVICES • ENVIRONMENTAL HEALTH DIVISION <br /> FORM (EH0015(REVISEo 10131196) <br /> DATE, ,` �( MASTERFILE RECORD INFORMATION <br /> .:.. .:: .. . .. . .... <br /> SHADED SEC TIONS FOR EHDUSEONIY OWNER ID CASEY <br /> r OWNER FILE <br /> COMPLETE THE FOLLOW/NG BUSINESS OWNER INFORMATION: C,lecxw OWNER CURRENTLYONFILE WIrliEHD. ... <br /> ....................................................... ................................... ....................... --...... ...-....... .... ...... <br /> BUSINESS OWNER PIIoNE <br /> i i <br /> 4 NAME <br /> ------- ----------- c� x <br /> FST---------7pi �e,,-E---------�20 I��C <br /> ..........._.................-.................-............................................................................................... <br /> ti SOL:Ste I TAx 10 i <br /> BUSINESS NAYE(If d/lferont from Owner Name '\ <br /> DINNER HOME ADDRESS <br /> 460 <br /> ��•�,p <br /> City STATE ZIP <br /> .I <br /> OWNER MAILING ADDRESS if0 FFERENbm <br /> T -oOwner Address i Attention:or Care of (optional) <br /> i Mailing Address City ` State ZIP i <br /> i <br /> • TYPE OF OWNERSHIP: <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCYd, COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FAOILITYID# �� CROSS REF ID* �` ACCOUNT-ID <br /> COMPLETE THE.FOLLOW/NG BUSINESS FACILITY INFORMATION: <br /> Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DIvisioN? YEs0 No ❑ <br /> Is this an EwsTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No <br /> BUSINESSIFACiLITY NAME(THIS WILL 9E THE NAME ON HEALTH PERMIT 1 <br /> FACILITY ADDRESS(IF FACIUTYIBA MOBILE FOOD UA1rORF000 VEHICLE USEC40MWSSARY ADDRESS Sul TEi BUSINESS PIar•E <br /> CITY IFFAcairYISA MOBILE FDOo UAVTOR FOOD VEI+ICLE USE GIMWBSARY ADpREsa GTYf STATE ZIP <br /> .BOARD OP SUPERVISOR DISTRICT..: :LOCATION CODE:: KEY1 KEY2 <br /> Mailing Address for If4ift►permit yDIFFERENTfivmFacility Address E Attention.orCare Of(opfioru!) <br /> I i <br /> 4 <br /> i Mailing Address City STATE i ZIP <br /> SIC CODE APN i CoruiENr <br /> THIRD PARTY BILLING INFORMATION: Complete if Billing Party is different from Business Owner Identified above. <br /> --......... ............__........._......._.......-----.--.............. •----- - - ._........_ .........-- . <br /> BuslNEss NAME i .Attention:or Care Of (optional) <br /> a <br /> IL Mailing Address PRONE <br /> t _ <br /> � <br /> Carr �: S7A7E 21P i <br /> 7 <br /> i <br /> ACCQUNTADDRESS for fees and chargesOWNER FACILITY/BUSINESS ❑ THIRD PARTY BILLING ❑ <br /> BILLING AND COAIPLIANCi:ACKNOWLEDCMENT: I, 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, ENFORCEVENT CIL-IRGEY and/or HouRi P CILIRG&Y <br /> associated with this operation will be billed to me at the address identified above as the ACCOUNTAnnl?FS-s 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 Fiowitr1L Laws and <br /> Regulations. <br /> PLEABE PRINT <br /> APPLICANT NAVE_, {� I a 1^� ^dj SIGNATURE 4.ZIA JLU <br /> TITLE l.• l V/l W� ^WY DRIVER'S LICENSE i PWSgq/. /1 <br /> Y I (PHOTOCOPY111 <br /> REORE0) Q LQ/ <br /> gpproved,Sy t7rasi Accolintblg.Ofean Prctiets(ne Completed P Date <br /> rY <br />