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SAN JOAQIIIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT r JERFILE RECORD INFORMATION For SHADED SECTIONS FOR EHD USE ONLY [�OWN7ERD# b !�, O CASE# OWNER FILE COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION: CHECK IF OWNER CURRENTLY ON FILE wires EHD BUSINESS PHONE OWNER NAME First MI last BUSINESS NAME(If different from Owner Name) Soc Sec or Tax ID# I OWNER HOME ADDRESS 1095 Get CITYoAlvikdZeA Stola T TE ZIP qe3 3 37 OWNER MAILING ADDRESS (If different from Owner Address),/ Attention or Care of {�S2Xl/ y— 19 " MAILING ADDRESS CITY STATE ZIP TYPE OF OWNERSHIP: CORPORATION❑ INDMDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ I /I FACILITY FILE FACILITY ID#: CO-OWNER ID#: ACCOUNT ID#: 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/FA ILITY NAME(this will he BusINESS NAME on the HEALTH PERMIT) FACILITY ADDRESS(If FACILITY is a MOBILE FooD UNIT or FD VEHICLE use the r:OMM1SSARY ADDRESS) BUSINESS PHONE I o�S S �1� 4 , At Aj #-e� Street Number irecti n Street Name Sree T Suite# CITY(If FAcILlrrls a MOBILE FDOD UNIT or FOOD VEHICLE use the CnMMissARY CITY) STATE ZIP, BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 MAILING ADDRESS for Health Permit(If DIFFERENT from Facility Address) Attention or Care Of MAILING ADDRESS CITY STATE ZIP SIC CODE: APN#: COMMENT: A[`=1VT AnQF?FSS-_for fees and charges: OWNER ❑ FACILITY/BUSINESS ❑ BII 1 INC' AND CoNtPt IANCF ACKNOXYLEOGNIFNT: I, the undersigned Applicant, certify that I am the Owner, Operator, or Authorized Agent of this Business, and I acknowledge that all PERhIIJ FEES,PENALT/ES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated With this operation will be billed to me at the address identified above as the AccoriNT ADDRrSS 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 FEDFRAI.Laws and Re ulations. APPLICANT NAME: SIGNATURE: Please Print TITLE: DATE DRIVER'S LICENSE# (PHOTOCOPY REQUIRED) Approved By Date Accounting Office Processing Completed By y,'. Date A PROGRAM{EHD 48-02-034 Pink}or WATER SYSTEM{EHD 46-02-003}form must be completed for each EHD regulated operation at this I OCATION except UST Program(Use SWRCB forms) EHD 48-02-035 Masterfile Record-Green 10/9/2003