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S/ -1N J013,01JI V COUNTY ENVIRONMENTAL HEALTH DT MENT ER1I_h RECORD INFORMATION AOR SHADED SECTIONS FOR EHD USE ONLY OW�_RID# �►AI�DJ_�7� CASE# OWNER FILE COMPLETFTf-IFFntlnwIAli-,RilclniGc,-(-iv mi=p 1nrcn0enArrnnt• BUSINESS OWNER'S NAME � �� BUSINESS /FACILITY NAME (This will be the 6uswEssNAMEon the HEALTH PERMIT) 13 � Ij PHONE: 2- 1�n b 1 First MI Last BUSINESS NAME (If different from Owner Name) 7S.Se orTaM ID # OMEADDRESSCITYZIP F 5Z©3LING ADDRESS (If different from Owner's Address) Attention or Care of MAILING ADDRESS CITY STATE ZIP TYPE OF OWNERSHIP: CORPORATION ❑ INDIVIDUAL PARTNERSHIP ❑ LOCAL AGENCY ❑ COUNTY AGENCY ❑ STATE AGENCY ❑ FED AGENCY OTHER ❑ FACILITY FILE jj FACILITY ID #: v CO-OWNER ID #: ACCOUNT ID #: R (—•"7 COfflPLETE THEFOLLOW/IVG BUS[N FSS FA.CII-_ITY /NFnRMAT:InAI- Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH Is this all EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ NO ❑ YES 414 NO ❑ BUSINESS /FACILITY NAME (This will be the 6uswEssNAMEon the HEALTH PERMIT) FACILITY ADDRESS (IfFACILITYiS a MOBILEFOOD UNITDr FooD VEHICLEuse the CoMMISSARYADDRESS) Z'71 L{ CD k_-1 �V Street Number 0,i�recffon Suite # BUSINESS PHONE 7 / I Z� `('J �C CITY (If FACILITY IS a MOBILE FOOD UNIT or FOOD VEHICLE use the COMMISSARY CITY) STATE ZIP y� l BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 MAILING ADDRESS forHealth Perrrt/t(If DIFFERENTfrom Facility Address) Attention or Care Of MAILING ADDRESS CITY STATE ZIP SIC CODE: APN#: COMMENT: ACCOUNTADDRESS for fees and charges: FACILITY/BUSINESS ❑ 31LLING AND COMPLIANCE ACKNOWLEDGMENT: 1, the undersigned Applicant, certify that I am the Owner, Operator, or Authorized Agent of this Business, and acknowledge that all PERMIT FEES, PENALTIES, ENFORCEMENT CHARGES and/Or HOURLY CHARGES associated with this operation will be billed to me at the iddress identified above as the ACCOUNTADDRESS for this site. I also certify that all information provided on this application is true and correct; and that II regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or EDERAL Laws and Requlations. APPLICANT'S NAME: C17if'.� {�tr/,,t SIGNATURE: �— Please Print TITLE: DATE "L •' DRIVEPHOTOCOPIY REQUIRED Approved By Date Accounting Office Processing Completed By / Date �V I/7 PROGRAM {END 48-02-034 Pink} or WATER SYSTEM {EHD 46-02-003} form must be completed for each EHD regulated operation at this LOCATION ;cept UST Program (Use SWRCB forms) I 48-02-035 Masterfile Record -Green '19/08