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SAN JOAQUIN COUNTY • LIC HEALTH SERVICES ♦ ENVIRONMENT HEALTH DIVISION <br /> FORM (EH0015(REWSED10/021861 <br /> DATE MASTERFILE RECORD INFORMATION <br /> SHADED SECPONSFOR EHD USE ON[Y (OWNER 10 -_ CASES= (,n.v a3�073 <br /> OWNER FILE <br /> CHECX IF OWNER CURRENTLYON FILE WlTr1EHD ❑ <br /> COMPLETETHEFOLLOw/NG BUSINESS OWNER INFORMATION.- ................................................................................. <br /> .............................................................. ..... ...... <br /> ' BUSINESS OWNER �C ✓� lJ <br /> PHONE <br /> NAME _________________—__--_____--------------- <br /> . <br /> MlLast ' <br /> .. .....................................................Fi......rst......................................... .............................................. ...................................... <br /> ! - SOC SEC/TA%ID# <br /> BUSINESS NAMEJ e)dUtlMOW=Br <br /> DRIVERS LICENSE# <br /> OWNER HOME ADDRESS <br /> o J `c STATE ZIPcity <br /> OWNER MAILING ADDRESS WDIFFEREATfrom OwnerAdd. Attention:arcane of (opeonol <br /> Mailing Address City State Zip <br /> TWE OF OWNERSHIP: <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ DTHER❑ <br /> FACILITY FILE <br /> FACILITY ID# '.' _ CROSS REF ID# ACCOUNT ID# <br /> COMPLETETHEFOLLOW/NG BUSINESS FACILITY INFORMATION.- <br /> Is <br /> NFORMAT/ON.Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DIVISION? YES ❑ No ❑ <br /> Is this an OUSTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ❑ <br /> BUSINESs/FAC ITY NAME(THISWI LBE THE NAM oN HEALTH PERMIT) <br /> FACILITY ADDRESS(IF FACIUTYISA N Uha- RFOOD V lE WECOMMISSARY ADDRESS) : SUITE# BUSINESS PHONE <br /> �o � <br /> CITYIFFAC/UTY1SAMOe1LEF0 UMTOM <br /> RFQQCVEMCLEDSECOMs&uw ADORESS CITY) i S ZPG� -3 30 <br /> BOARD OF BUPERVISOR DISTRICT 'LOCATIONCODE KEH REY2 <br /> Mailing Address/or Hes/fh Permit irDIFFERENrfio/n Faei[ityAddreas Attention:or Care Of(optional) <br /> STATE ZIP <br /> Mailing Address City <br /> SIC:CDOE APN# COMMENT: <br /> THIRD PARTY BILLING <br /> INF�O,IRM.�AtTrIOoN✓: Complete <br /> om lete,if <br /> Billing <br /> Tlin PaIr1Yis <br /> different fromtiDBusiness <br /> � Owner <br /> -qwn�e// <br /> raI�dent�edabove. <br /> . .........g ...... . <br /> ........................................................................................................_ .................. OfGreOf <br /> BUSINESS NAME s(Opb <br /> — <br /> 1 cepgl STI <br /> Mailing Address <br /> CITY \ G STAJE LP J <br /> CIG <br /> Aggq_qXE4DoRE5S for fees and charges OWNER El FACILITY/BUSINESS ❑ TCHI� LRD_PARTY BILING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I, the undersigned Applicant, certify that I am the Owner, Operator, or Authorized <br /> Agent of this Business, and I acknowledge that all PE2tHT FEES, PEVALT/ES, 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. <br /> PLEASE PRINT <br /> APPLICANT NAME SIGNATURE <br /> TITLE DRIVER'S LICENSE# <br /> (PHOTOCOPY REQUIRED) <br /> ".Approved By '.- Date <br /> Accounting Office Processing CompletedDate a ?' <br />