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SAN JOAOMICOUNTY ENVIRONMENTAL HEALTH D RTMENT MTERFILE RECORD INFORMATION FORN. SHADED SECTIONS FOR EHD USE ONLY OWNER ID # i4jooz/ CASE # OWNER FILE COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION: CHECK /F OWNER CURRENTLY ON FILE W/THEHD BUSINESS OWNER'S NAME O'F;' I' () ncrn _ PHONE: First MI Last BUSINESS NAME (If different from Owner Name) -- VV-CA ' S•A---OlUi On 1( 6,) it 1* 9 •4 ilsY) Soc Sec or Tax ID # OWNER'S HOME ADDRESS Crry STATE ZIP OWNER'S MAILING ADDRESS (If different from Owner's Address) Attention orCare of MAILING ADDRESS CITY STATE ZIP TYPE OF OWNERSHIP:, CORPORATION INDIVIDUAL 111 PARTNERSHIP El LOCAL AGENCY El COUNTY AGENCY El STATE AGENCY EI FED AGENCY OTHER 0 FACILITY FILE FACILITY ID #: p7,60 CO-OWNER ID #: oo-H-4 /--77 COMPLETE THE FOLLOWING BUSINESS FACILITY INFORMATION: Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL 11es w o-ramc•rr9 Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES HEALTH YES Ni( No • • No 111 BUSINESS/FACILITY NAME (This will be the BUSINESS NAME 0n the HEALTH PERMIT) S -7, '6i1A 61 n 1 L2 V3I "1-. 57 I FACILITY ADDRESS (If FAciurvis a MOBILE FOOD UNITor FOOD VEHICLE Use the 9-6100 Street Number Direction Street Name COMMISSARY ADDRESS) Street rive Suite # BUSINESS PHONE CITY (If FACILITY is a MOBILE FOOD UNIT or FOOD VEHICLE >1-7) Cl(--1711-1 use the COMMISSARY CITY) STATE . ZIP Ci 2A) BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 MAILING ADDRESS for Health Permitlf D/FFERENT from Facility Address) Attention orCare Of MAILING ADDRESS CITY STATE ZIP SIC CODE: APN #: COMMENT: ACCOUNT ADDRESS for fees and charges: OWNER FACILITY/BUSINESS 0 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 all PERMIT FEES, PENALTIES, ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation will be billed to me at the address identified above as the ACCOUNT ADDRESS 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 JoAQuirsi COUNTY Ordinance Codes and/or Standards and STATE and/or FEDERAL Laws and Regulations. APPLICANT'S NAME: SIGNATURE: Please Print TITLE: DATE DRIVER'S LICENSE # (PHOTOCOPY REQUIRED) Approved By Date Accounting Office Processing Completed By / Date z4/417 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 LOCATION except UST Program (Use SWRCB forms) END 48-02-035 8/19/08 Masterfile Record -Green