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SAN JOAQIr" ,'OUNTY ENVIRONMENTAL HEALTH DEP TMENT <br /> 4- <br /> llrrTSTERFILE RECORD INFORMATION FORK <br /> ID# <br /> SHADED SECTIONS FOR EHD USE ONLY OWNER IP <br /> OWNER FILE <br /> CHECK IF OWNER CURRENTLY ON FILE mTH EHD <br /> COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION: <br /> rB <br /> SINESS !`.�f�� PHONE <br /> NER NAME First Ml Last <br /> SINESS NAME(If different from Owner Name) SOC Sec Or Tax ID# <br /> OWNER HOME ADDRESS <br /> STATE ztP <br /> CITY <br /> OWNER MAILING ADDRESS (If differeLAddrm",$) Attention or Care of <br /> rrS35 �. 0A0STATE zIP <br /> MAILING ADDRESS CITY C`,DS <br /> TYPE OF OWNERSHIP: J <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY El FED AGENCY ElOTHER El <br /> FACILITY FILE <br /> Accourtr ID#: <br /> FACILITY ID#: } t't d V s 6 L�7— CO-OWNER 1D#: <br /> COMPLETE THE FOLLOWING BUSINESS IFACILITY INFORMATION: <br /> Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO ❑ <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? 4Es ❑ No ❑ <br /> BUSINESSIFACILITY NAME(This will be the BUsINEss NAmeon the HEALTH PERMIT) <br /> r ..�ea�canwv Ann ESI BUSINESS PHONE <br /> FACILITY ADDRESS{If FAGLI7Y is a MOLE FOOD Urlrr or Fo�o/d Vera//+��cr�use the-^"------- - R—, <br /> ''�8 �, Alwjoei t W Suite# <br /> r mcgon <br /> STATE zip <br /> CITY(If FACILITY Is a MOBILE Foov UNIT or FOOD VEHICLE use the Q3bWlM3AEY CM3 y s 2 0 <br /> r KEY1 KEY2 <br /> BOARD OF SUPERVISOR DISTRICT Ob ` LOCATION CODE p <br /> TJ <br /> MAILING ADDRESS for Health Pennit(If DIFFERENT from FacifityAddress) Attention or Care Of <br /> MAILING ADDRESS CITY STATE ZIP <br /> SIC COD <br /> CoMNlEKr: <br /> drf nrlur AnDRESs fOr fees and charges: OWNER ❑ FACILITYIBUSINESS ❑ <br /> 1311.7 INC. GmFNT: L the undersigned Applicant, certify that I am the Owner, Operator, or Authorized Agent of this <br /> Business, and I acknowledge that all PERMI,,'FEES,PENALTIES,ENFORCEMENT C11ARGES and/or HOURLY C11ARGES associated with this operation will be <br /> billed to me at the address identified above as the AccorlNTADDRESS for this site. I also certify that all information provided on this application is true and <br /> correct; and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards <br /> and STATE and/or FEDFRAL Laws and Regulations. <br /> APPLICANT NAME: SIGNATURE: <br /> Please Print <br /> DATE DRIVER'S LICENSE# <br /> TITLE: <br /> Approved By S Date Gf Accounting Office Processing Completed By Date ?� 31 a . <br /> A PROGRAM{EHD 4"2-034 Pink}or WATER SYSTEM{EHD 46-02-003}form must be completed for each£IID regulated operation at this I ORATION except <br /> UST Program(Use SWRCB forms) Maste�le Record-Green <br /> EHD 48-02-035 <br /> 101912003 <br />