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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1,STERFILE RECORD INFORMATION FO.1 <br /> SHADED SECTIONS FOR EHD USE ONLY OWNER ID# Q bO r7 CA8E# <br /> OWNER FILE <br /> COMPLETE THEFOLLOWWG BUSINESS OWNER INFORMATION.- CHECKIF OWNER CURRENTLYONFILEHYTHEHD❑ <br /> BUSINESSI First MI v O Lasf PHONE' ,.` <br /> OWNER'S NAME r b 6 - �+ �V <br /> BUSINESS NAME(If df9emnt from Owner Name) SOC See OrTax ID# <br /> p r p,-WS <br /> OWNER'S HOME ADDRESS <br /> Cln <br /> sm zip <br /> OWNER'SMAILING ADDRESS (If diBerentfromOwner's Address) Attention orCare OF <br /> MAILING ADDRESS CITY ST <br /> "- <br /> TYPE OF OWNERSHIP: <br /> CORPORATION❑ INDIVIDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY OTHER❑ <br /> FACILITY FILE <br /> FAcIUTYID#: GU -1 S CO-OWNER ID#: ACCOUNTID#: Aomssqs <br /> COMPLETE THEFOLLOWING BUSINESS FACILITY INFORMATION: r� <br /> IS this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES ❑ Lr <br /> NO <br /> nce..or..cu.� <br /> Is this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ NO D <br /> BUSINESs/FACILITY NAME(This will bel the BUSINEss NANEon the HEALTH PERMIT) <br /> G }A L S <br /> FACILITY ADDRESS(If FACILITYIS a NowLEFOOO UNITor FODD✓EHICLEOSS the COMMISSARY ADDRESS I BUSINESS PHONE <br /> Igo hlF7 Gh erok� �� SDlfep <br /> CITY(If FACILITY Is a MOBILE FPQD UNn Or FOOD VEHICLE USS,the COMMswy Cnv) STATE ZIP <br /> BOARD OF SUPERVISOR DIBTRICr LOCATION CODE KEYT KEY2 <br /> MAILING ADDRESS for HBa/th Pen ft(If DIFFERENTfrom Feci/ifyAddmss) Attention_Care <br /> Of <br /> MAILING ADDRESS CITY STATE ZIP <br /> SIC CODE: APN#: d- 160-0 J OOMMENT: <br /> ACCOUNTAODRESS for fees and charges: OWNER ❑ FACILITY/BUSINESS ❑ <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and <br /> I acknowledge that all PERMIT FEES,PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this Operation will be billed t0 me at the <br /> address identified above as the ACCOUNTADDRESS for this site. I also certify that all information provided on this application is true and correct;and that <br /> all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or <br /> FEDERAL Laws and Regulations. <br /> J <br /> 'APPLICANT'S NAME: I 'f"Y/.� SIGNATURE: <br /> Please Print /�j 6 DRIVER'SLICENSE# <br /> TITLE: ,r ATE r:7 7 p PHOTOCOPY REQUIRED <br /> Approved By /�. Dete /I.'l /�.�1 O Acccu ding Mce Prviceuing a ,,I led By neuI \3 b <br /> A { 2 Pink)or WATER SYSTEM(EHD 464maYilli,tonn tmislbe completed for each EHD regulated operation at this LOC <br /> except UST Pro5ram(Use SWRCB forms) <br /> EHD 48-02-035 Masterfile Record Green <br /> 8119/08 <br />