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-`" SAN J0-1N COUNTY ENVIRONMENTAL HEALTH E``XRTMENT MASTERFILE RECORD INFORMATION FORM SwIDrDSEcnmFaREHDUsEOxI.Y OWNER ID#t 2 CASE# OWNER FILE COAOU7ETHEFOUOWINOSUSINESSOWNER IMFORNA17m. CfroxIFOWNER C1fRREM VaVFlLEwrMEHD❑ BUSINESS — . -77%,rO7Hy ,e I V r 1,1:)x OWNER'S NAME ��$t'�' �:• D7-7-0,112 PHONE: p a first M! Lasts BUSINESS NAME(If dtAerentfiamOwner Name) Soe Sec orTax ID# ` OWNER'S HOME ADDRESS CITY G � Sra zip OWNER'S MAILING ADDRESS(if dHfereW fnwnOwnees Address)//^l- Atbwdh n arCare of cou-- .2En QTTOA&C— MAILING ADDRESS CITY STATE I ZIP rYPEor O*NRWH1F- CORPORATION INoIVIDUAL❑ PARTNERSHIP[IENCY LOCAL AG ❑ COUNTY AGENCY❑ STATE AGENCY[IFED AGENCY❑ OntER El FACILITYFILE FACILITY ID#: 3 Co-OWNER ID#: ACCOUNT ID# CEWPLETE7HEFOLLOWIIVG BUSINESS FACILITY IIVFQRMATlON: Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES , No El1-sthisan Ewsr;NG BusinessLOCATIONbuka NEw7Vmofregulated Business? YES ❑ No BUSINESWAcyTy NAME(This will be the Bt�rAESB/YUWm th HEALTH PERMIT) iVV viRo FACILITY ADDRPP-q lr.Ranum M s�,.��,,,,r,.�.,r F(�ytinatFuaeihe Cam BUSINESS �PHONE � �e�PC() Sue# 7; (IIFA.M a MEF..utr Vq�jec.Ee tCorm irrSTATE LP=�� qC- 8 # 9 �s2 BOARD OF SUPERVISOR DISTRICT I. rAroN CODE KEY1 KEY2 MAILING ADDRESS fOrHealih Pernrft(ff OIFFERE_IVT_from Fac#*Addiessf Atbmdm orCare Of � MAIumG ADDRESS CITY STATELP �E -L 9--�, 7 SICCODE: APN# COM>s emr. AWOUWALOWSS FAM�wufor fees and charges: OWNER FACILI7YBUSINESS ❑ BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,codify that I am the Owner Operator,or Authorised Agent of this Business,and I acknowledge that all PIE wT FEES,PENAL77ES,ENFORcevEn CHARGES andfor HouRLY CHARGES associated with this operation will 6e billed to me at the address Identified above as the ACC2VNTAODREss 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 andfor Standards and STATE and/or FEDERAL Laws and ReguLations. APPLICANT's NAME: 0,9-91W 7-0 VE SIGNATURE: Please Print TITLE: DATE 7"46.j/FlR' Lro I Approved SY Q 3-z.4Apaountns pats 7 0 Olflce Processing Oompleted By A PROGRAM(EHD 48-02-034 Pink}or WATER SYSTEM Z640 48-02403}form MW be completed for Mph EHD regulated operation at this LOCATION except UST Program(Use SWRCB forms) EHD 48-02-035 Masterfile Record-Green 11/27/07