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o I <br /> y. SAN JOAQUIN COUNTY UBLIC HEALTH SERVICES • ENVIRON TAL HEALTH DIVISION <br /> • I"oRM {EH OOfS(REVIEefOlO2196} <br /> . <br /> 'DATE MASTERFILE RECORD,INFORMATIOI. <br /> Sl/AOEDSECTIONSFOR EHDUSEONL7 11 <br /> Y OwNERIDIIlGZ CASE# <br /> OWNER FILL` <br /> COMPLETETHEFOL LOW/NGBUSINESS OWNER INFORMATION. CNEcicIF OWNER CURRENTLYON FILE WrI EHO <br /> -------------- .........- <br /> BUSINESSOWNER AK/S ..................................... .......................................illl....-.............. <br /> UW- <br /> PHONE <br /> NAME — ----- <br /> ................................... ..... ... ........ Frs. ........ — _—_ — ----- 2tiq 1 ^��... .. .1............................ .rm............. <br /> II. <br /> BUSINESS NAME(If dhTervat from Owner Name) SOC SEC ITAX ID a <br /> OWNER ORNER's LICENSE# I! <br /> " L A510 ! G� 915 2-x-1�- sT� ZIP�l�✓�LI <br /> OWNER MAIUNGADaness .DIFFERENTfirmDwnerAdd. Attention.,orCare of(opiYonal) <br /> NA <br /> Mailing address City, 'O f`J' A4A4--33 sta Zip <br /> 1/-- <br /> TYPE OF OWNERSHIP' LL <br /> CORPORATION❑ INOIVIDUAL PARTNERSHIP© LOCAL AGENCY❑ COUNTY AGENCY© STATE AGENCY❑ FEU AGENCY❑ QfHER❑ <br /> FACILITY FILE <br /> :...:CR4sSREF:lD#.... :: AeeOUN.r.II)ap..... . <br /> aFACILITX:ID .......:.. ..,. <br /> COMPLETETHEFOLLOW/NG BUSINESS FACILITY INFORMATION.- <br /> Is <br /> NFORMATION.Is this a New Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DIVISION? Yas © Np <br /> 1 <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ NO1 <br /> Busiwss1FACILITY NAME(THIS WILL BE THE NAME ON HEALTH PERMIT) ' <br /> ori <br /> FACILITYAOORESS(IFFAcxny1SAMOSILEFOODUAVTORFOOD V&WLEUSECOMMiSSARYADDRESS SUITE# BUST ESS NE � <br /> '��.--- <br /> E CITY IFFAcR?YIS A MODILEFOOD UANTOR FOOD V&*CLEUSEC.oMMISSARYADORESSQTY} (STATE <br /> I ZIP <br /> 6©ARDOFSIffiERIIISOR:DIS7RICT;? ....;5. :_i.Ol:ATIONCODE ., .....5. - <br /> ? Mailing Address for Health Permit ifDIFFERENT firm Fac(fifyAddress Attention.or Care Of(opdional) <br /> S Mailing Address City E STATE ZIP <br /> ,II <br /> -- -- - - - <br /> SIC CODE APN I� COIitMENi <br /> p............................_g........ 1!...s differentfrom Business Owner (dented'above. <br /> THIRD PARTY BILLING INFORMATION: Complete if Billie Pa % ..................................................................................................I.................... <br /> i BUSINESS NAME ? Attention_orCare Of (opEional) I <br /> II <br /> Mailing Address i PHONE <br /> I, <br /> Cm STATE Zip II <br /> ACCOUNT.4DOBF-W for fees and charges OWNER ❑ FACILITY/BUSINESS THIRD PARTY BILLING ❑ <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 PERvrr FEVs, PENALTIES, ENFORCEMENT CHARGES and/or HOURLY LARGESassociated 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 perfokfined in <br /> accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or FED19RAL j6ws and <br /> Regulations. <br /> PLEASE PRINT <br /> APPLICANT NAME V v'►�' SIGNATU I I <br /> TITLE M I/L- 4VH�J('jl � DRIVER'S LICENSE If <br /> (PHOTOCOPY REQUIRED) <br /> Approllad.By Date .: llacounting Office-procgsiiingompleted By Date <br />