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SAN JOA--'IN COUNTY ENVIRONMENTAL HEALTH V '%RTMENT <br /> ..,ASTERFILE RECORD INFORMATION Fok.I <br /> SrrAovSEcTioNsFoREHAUse ONY OWNERID# � ='_7 CASE# <br /> OWNER FILE <br /> COMPLETE THERXLOW/AGBUSINESS OWNER/NFORM4TION. CHECKIFOWNER CURRENTLYONRLEWfTHEHD❑ <br /> BUSINESS ; PHONE: <br /> OWNER'S NAME Flrst MI Last <br /> BUSINESS NAME(If different frcmOwner Nome) So Sec orTax ID# <br /> pS <br /> OWNER'S HOME ADDRESS: ' J- lM• f D� �Z� <br /> CITY L,`,ACev\ STATE C.44 zip 9 S_--13& <br /> OWN ER'S MAIUNG ADDRESS(If dfferent iromOwner'e Addreae) A ttention orCare of <br /> MAILING ADDRESS CITY _ STATE ZJP <br /> TYPE OFOWNERSHIP. <br /> CORPORATION INDMDtIAL❑ PARTNERSHIP❑ LOCALAGENOYO COUtMAGENCY❑ STATEAGENCY❑ FEDAGEMCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID#: 777 7)7)7 177-477 CQ-OWNER ID#: ACCOUNT ID#: <br /> COMPLETETHEFOLLOW1NGBUSINESS FACILITY/NFowAnow <br /> Is this a NEw Business LOCATION or VEHICLE not previously regulated by the ENVRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> Is this an ExtSTNG Business LOCATION but a NeNTYPE of regulated Business? YES No ❑ <br /> B U SINESS/FACL rry NAME(This WO be the BusmssNAuuon the HEALTH PERM R) A PN: <br /> OIr r1 i e L r&f <br /> FA cILITY ADDR ESS of FAcxwyls a Mos/LE FOOD tutor FOOD VEwcLE use the COMMISSARY ADDRESS) BUSINESS PHONE: <br /> +D V--d t���e-, CA 01 sa3 b <br /> CITY(If FAcrLrrY Is a MxtLE Foca UNrror Fow VEwcif use the COMMISSARY CrM STATE ZJP <br /> CA 9 Sd,3 <br /> BOARDOFSUPERMSORD[4TR1CT LOCATIONCODE ItEY1 It1 Y2 <br /> MAILING ADDRESS tbrHealf Pennit(If DIFFERENTfrom FaadyAddress) Attention orCare Of <br /> MAILING ADDRESS CITY STATE ZIP <br /> EMAILADDRESSFOR INVOICE ( I 4 e i INVOICE <br /> INVOICES EMAIL 1 � o f• h✓11� 1 1 EMAIL2 <br /> EMAILADDRESSFOR PERMIT PERMIT <br /> OPERATING PERMITS EMAIL'I (NM' e1• •" 'rI EMAIL2 <br /> A CCOUNTADDRESSfor fees and charges: OWNER FACILITY/BUSINESS <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certifythatl am the Owner,Operator,or Authorized Agento f this Business, <br /> and Iacknowledge thatallPERMTF�S,PENALTIES,E:NFORCaIENTCn4RGEsand/or HouRLYCHARGEsassociated with this operation will bebill ed to me at <br /> the address Identified above as the AccoujvTAoDREss for this site. I also certify thatall information provided on this application Is true andcorrect; and <br /> that all regulated activities will be performed In accordance with all applicable SAN JoAQUN COUNTY Ordinance Codesand/or Standards and STATE and/or <br /> FEDERAL Laws and Regulations. <br /> APPLICANT'SNAME: 1 c UV '8 1� SIGNATURE: oml:��o <br /> se Print f <br /> TITLE: W'0 tfVDATE I It Ia.021 DRIVER'SICEN <br /> Appraed By Date Accounting Office ProcamIrg Completed By / Data J <br /> A PROGRAM(EHD4&02-034Pink)orWATER SYSTEM(EHD46-02-003)form Musj bacompleted foreach EHDregulated operation at this LOCATION <br /> except UST Program(Use SWRC9 forms) <br /> EHD 48-02-035 Masterfile Record-Green <br /> 8/1412020 <br />