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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT kSTERFILE RECORD INFORMATION FO SHADED SEcn=FOR EHD USE ONLY OWNER ID# QI .\oO �C� x CASE# OWNER FILE J COMPLETE THEFOLLOW/NG BUSINESS OWNER INFORMATION. CHECK/F OWNER CURRENTL voN FILE wtrH EHD❑ BUSINESS / E,�/ 1 � Lc PHONE: First Last OWNER'S NAME � Q MI BUSINESS NAME(R deateIAntAlram Owner NamO Soc Seo orTex ID# 1 3- �� OWNER'S HOME ADDRESS CITY sr'OC 6%,1 p✓ C-t� STA ZIP /3 Jc—�2 'S- OWNER'SMAILING ADDRESS (NdlbnwItih;mO%mseaAddrasa) Attention arCare of MAILINGADDRESS CITY STATE ZIP TYPE OF OWNERSHIP: CORPORATION❑ INDIVIDUA PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY OTHER❑ FACILITY FILE FACILITY ID#: 0D nS CO-OWNER ID#: ACCOUNT ID#: q 2 COMPLETE THEFOLLOw/NG BUSI NESS FACILITY INFORMATION: IS this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES ❑ NO ❑ nro.e.r.c�M IS this an ExISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ NO ❑ BUSINESS/FACILITY NAME(This will a auslREss NAME5on the HEALTH PERMIT) r FACILITYADDRESS(If FAcmiT la a MOa&EAD UNTor Food VEHIcL uae theCOMMISSARY ADDRESS) �� BUSINESS PHONE Suite y*- qq CITY(If FAct Yrs a MoaiLEF000 UNnor FOOD VEHIcLEuse the COwWsSmYCrrYSTA P * I �0� BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1KEY2Q MAILING ADDRESS for Health Permit(If DIFFERENTinnm FacilityAddress) Attention arcane Of MAILING ADDRESS CITY STATE ZIP SIC CODE: APN#-. BIW O COMMEW: ACCOUNTADDRESS for fees and charges: OWNER ❑ FACILITYBUSINESS ❑ 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 tome at the 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 all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or FEDERAL Laws and Regulations. '` PLICANT'S NAME: (�/�L�/tib• _�iG ra^-�/��LC SIGN •TURE: Please Print TrttE � � pTE�JO DRIVER'S LICENSE# /n� PHOTOCOPY REQUIRED Approved BY l Data 91/'V li✓1o! Acc Ming Omce Processing C pleted By DM A PRGGRAr(E O 48-02-6 Pink)or WATER SYSTEMMr'(EHD 48-O2YQIG"ornr muatbe completed for each END regulated operation at thisLOC except UST Program(Use SWRCB forma) EHD 48-02-035 Masterfile Record-Green 8119108