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SHADED SECTIONS FOR EHD USE ONLY SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Il/IAS T ERFILE RECORD INFORMATION FORM COMPLETE THEFOI.LOWIIV13MI1SINFSS "VV NFR /vr-ijP nartnAr _.. _.. ...-.I—I TYPE OF OWNERSHIP: CORPORATION INDIVIDUAL ❑ PARTNERSHIP ❑ LOCAL AGENCY ❑ COUNTY AGENCY ❑ FACILITY FIl ,E FACILITY ID #: I CO-OWNER ID #: COMPLETE THE FOLLOW/NGBUSiNESS FACILITY /nlFnuttfarmnt� STATE P.GENCY ❑ FED AGENCY OTHER ❑ ACCOUNT ID #: – �rr.inuwU IS this a NEW BUSIneSS LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES NO ❑ Is this an ExISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ❑ BUSINESS late PHONE:r_W BUSINESS/FACILITY NAME (This will be the BUSlIVESSNAmEon the HEALTH PERMIT) OWNER'S NAME First 1141 - Last BUSINESS PHONE _ /�/ 1 ) �� `f (J(� STATE ZIP 40 BUSINE 5 NA E (If ' erent from Owner Name) Soo Sec orTax ID # BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 VrA OWNER'S HOME AD RESS CITY / s S6*E ZIP C) �%/�i► ,7E G CJ MAILING A D D R E§sfor Health Permlt(IfDIFFERENTfrom Facility A ddress) V . 1 Attention or Care Of OWNER'S MAILING ADDRESS (If different from Owner's Address) Attention or Care of MAILING ADDRESS CITY) 1 (/ 00( STATE Zoe 16 SIC CODE: MAILING ADDRESS CITYS COMMENT: 1 ZIP ef j5 TYPE OF OWNERSHIP: CORPORATION INDIVIDUAL ❑ PARTNERSHIP ❑ LOCAL AGENCY ❑ COUNTY AGENCY ❑ FACILITY FIl ,E FACILITY ID #: I CO-OWNER ID #: COMPLETE THE FOLLOW/NGBUSiNESS FACILITY /nlFnuttfarmnt� STATE P.GENCY ❑ FED AGENCY OTHER ❑ ACCOUNT ID #: ACCOUNTADDRESS for fees and charges: FACILITY/BUSINESS TILLING AND COMPLIANCE ACKNOWLEDGMENT: I, the undersigned Applicant, certify that I am the Owner, Operator, or Authorized Agent of this Business, and acknowledge that all PERM/T FEES, PENALTIES, ENFORCEMENT CHARGES and/or HOURLY CHARGES associated Wlth thlS OperatlOn WIII be billed t0 me at the Iddress identified above as the AccouNTADDF% for thiss e. I also certify that all information provided on this application is true and correct; and that II regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or 7EDERAL Laws and Regulations.. A APPLICANT'S NAME: TITLE: Approved By Please Print DATE SIGNATURE: DRIVER'S LICENSE # (PHOTOCOPY REQUIRED Accounting Office Processing Completed By �St7 PROGRAM {EHD 48-02-034 Pinlc} or WATER SYSTEM {EHD 46-02-003} form must be completed for each EHD regulated operation at this LOCATION Kcept UST Program (Use SWRCB for �D 48-02-035 Masterfile Record -Green 19/08 IS this a NEW BUSIneSS LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES NO ❑ Is this an ExISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ❑ BUSINESS/FACILITY NAME (This will be the BUSlIVESSNAmEon the HEALTH PERMIT) FACILITY ADDRESS (If FACILITYIS a MOBILEFOOD UNITor FOOD VEH/CLEuse the COMMISSARY ADDRESS) � n SU>n t � bar DirectLan Suite # BUSINESS PHONE _ /�/ 1 ) �� `f CITY (If FACILITY] MOB FOOD UNITor FOOD VEHICLE use the COMMISSARY CITY) ov' STATE ZIP 40 BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 MAILING A D D R E§sfor Health Permlt(IfDIFFERENTfrom Facility A ddress) V . 1 Attention or Care Of MAILING ADDRESS CITY) 1 (/ 00( STATE SIC CODE: APN 9: COMMENT: ACCOUNTADDRESS for fees and charges: FACILITY/BUSINESS TILLING AND COMPLIANCE ACKNOWLEDGMENT: I, the undersigned Applicant, certify that I am the Owner, Operator, or Authorized Agent of this Business, and acknowledge that all PERM/T FEES, PENALTIES, ENFORCEMENT CHARGES and/or HOURLY CHARGES associated Wlth thlS OperatlOn WIII be billed t0 me at the Iddress identified above as the AccouNTADDF% for thiss e. I also certify that all information provided on this application is true and correct; and that II regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or 7EDERAL Laws and Regulations.. A APPLICANT'S NAME: TITLE: Approved By Please Print DATE SIGNATURE: DRIVER'S LICENSE # (PHOTOCOPY REQUIRED Accounting Office Processing Completed By �St7 PROGRAM {EHD 48-02-034 Pinlc} or WATER SYSTEM {EHD 46-02-003} form must be completed for each EHD regulated operation at this LOCATION Kcept UST Program (Use SWRCB for �D 48-02-035 Masterfile Record -Green 19/08