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SAN JOAO-QIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT . ,STERFILE RECORD INFORMATION FOI+ SHADED SECRONSFOREHD USE ONLY OWNER ID# owob Z� CASE# OWNER FILE COMPLETE THEFOLLOW/NG BUSINESS OWNER INFORMATION.' CHEcR iF OWNER CuRRENrLYav FicE HvrHEHD❑ BUSINESS PHONE: OWNER'S NAME via caa:2had O©Frst MI Last BUSINESS NAME(if a7Kereatfromowner Name) Soc Sec orTax ID# C /h lS `car?S OWNER'S HOME ADDRESS CITY STATE ZIP /] �s OWNERS MAILING ADDRESS (Ifdillerent from Owner's Addrece) Atlandon wCare of C• _I J MAILING ADDRESS CITY STATEZIP TYPE OF OWNERSHIP: CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY OTHER❑ FACILITY FILE FACILITY ID#: U CO-OWNER ID#: ACCOUNT ID#: 1 s 3 J COMPLETE THEFOLLOWWG BUSI NESS FACILITY INFORMATION; Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES 01 NO ❑ nceweru�uTo Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ❑ BUSINEss/FACILITY NAME(This ill be the SusINE55NAMEOn the HEALTH PERMIT) A `s00S FACILITY ADDRESS(6 FAciurris a MOBILEFOoo UNiror FOOD VEHic[Euse the COMMISSARY ADDRESS) BUSINESS PHONE See* a CITY(N FAciu is a MoRt EFooD UNrtor F000 VEx the COMMssmy cC I STATE ZIP BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEPI KEY2 MAILING ADDRESS for Health Permft(If DIFFERENTfrom Facility Address) Attentlon wCaro Of MAILING ADDRESS CITY I STATE ZIP SIC CODE: APN#: 3 COM Z ACCOUNTADDRESS for fees and charges: OWNER ❑ FACILITY/BUSINESS ❑ BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,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 to me at the address identified above as the ACCOUNT ADDRESS 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. APPLICANT'S NAME: 649(G Cro' NF1 LC SIGNATURE: Please PrintTITLE: r DATE DRIVER'SLICENBE# s1L �b PHOTOCOPY REQUIRED Ver Approved By 1174 Date y 1 D `7n1-/I A—Ung Olrice Pronesein9 Canple W By 1�� Date \ 2 O A PROGRAW( 48-02 Pink)or WATER SYSTEM{EHD 46412411IQI .bDrm mueFbe completed for each EHD regulated operation at this LJOCATIOW except UST Program(Use SWRCB forma) EHO 48-02-035 Masterfile Record-Green 8/19108