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SAN JOAQUIN COUNT-- PUBLIC HEALTH SERVICES ♦ ENVIRO -NTAL HEALTH DIVISION rs FORM (EH 00 15(REVISED IO/02/96) DATE L{ J. — f� t� MASTERFILE RECORD INFORMATION 11 SHAOEDSEC7/ONS FOREHDUSEONLY CwNERID# CASE# OWNER FILE COMPLETE THEFOLLOWING BUSINESS OWNER INFORMAT/ON: CHECK/F OWNER CURRENTL YON FILE WITH EHD ................................................................................................................................................................................................... ..................... ....................................................... BUSINESS OWNER PHONE 'i3-�_ �� NAME _________________�_—_�___—_____________—__—. ..................................................................Firsl.......................................M(...............................................m(...................................... BUSINESS NAME(If different from Owner Name) ' Soc SEC l TAx 10# OWNER HOME ADDRESS Lj�C� T�I��Ij DRIVER'S LICENSE# ci"Y I� STATE` ZIP OWNER MAILING ADDRESS ifD/FFEREAff from OwnerAddress Attention:or Care of (optional) Mailing Address City State Zip TYPE OF OWNERSHIP: CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY('� COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ FACILITY FILE FACILITY ID# l} f� CROSS REF ID# AccouNTID4. COMPLEETETHEFOLLOW/NG BUSINESS FACILITY INFORMATION. Is this a NEW Business LOCATION or VEHICLE not Previously regulated by the ENVIRONMENTAL HEALTH DIVISION? YES NO ❑ Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No,0 i BUSINESs/FACILITY NAME(THIS WILL BE THE NAME ON HEALTH PERMIT) 1 n/� {Jw Y�Jv 11KJv FACILITY ADDRESS /FFACILITYISA AfosxEFOOo UN/TORFOOO VEH/CLEUSECOMMISSARY ADDRESS) SUITE# : BUSINESS PHONE CITY fFFACILITYISA MOBILEFooD UAYTORFOOO V&NcLEUSECOMMISSARY ADDRESS CITY) STATE-. ZIP BOARDOFSUPERVISORDISTRICT L.00ATIONCODE KEY7. Mailing Address for Health Permit ifOIFFEREArr from Facility Address Attention:or Care Of(optional) Mailing Address City STATE i ZIP SIC CODE_ APN# COMMENT: THIRD PARTY BILLING INFORMATION: Complete if Billing Party is different from Business Owner Identified above. ...................................................................................................................................................................................•............................................................................................................ , BUSINESS NAME ] Attention:or Care Of(optional) ll ^ Mailing Address �� a si PHONE i CITY 1 ' STATE l E ZIP ftA ACCOUNTAn RESS for fees and charges OWNER ❑ FACILITY/BUSINESS ❑ THIRD PARTY BILLING ❑ BILLING AND COMPLIANCE ACKNOWLEDGMENT: I, the undersigned Applicant, certify that I am the Owner, Operator, or Authorized Agent of this Business, and I acknowledge that al PERVIT FEES, PENALTIES, E,VFORCE.tifENT CHARGES and/or HOURLY CHARGES associated with this operation will be billed to me at the address identified above as the AccoUNTADDRESS 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 Regulations. APPLICANT NAME �(1 PLEASE PRINT RINT SIGNATURE ILntW' �Gvi � TITLE / y (✓I I\1�ULf DRIVER'S LICENSE# (PHOTOCOPY REQUIRED) Approved By z Date 05/&� Accounting Office Processing Completed By (; Date ��