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�� RE �'=��PMASTE HLAL <br /> S/ItDFDSFCl/ Ty SER V/CES <br /> /VSFO�,yO-�SF�Y IV VI <br /> — E F� CO ENTAL <br /> ::O1YNEN ID RE 'D INF( AW <br /> HEALTy p1y/Sloy <br /> )YFO(L OW/NG <br /> "�'b GAaex ' <br /> BU91NE8a a+'NEa BUSINESSO ID / <br /> ER FILE <br /> Y <br /> WNE <br /> MAT/ON: <br /> NAYE ....... <br /> —r Fvs7 ^ N <br /> --- <br /> BUSINESS <br /> AME ...................... � ....... ...................u... ......N..'f.... / , <br /> e CT,EC <br /> (If <br /> Owner Name)............................... �( OWNER ._.._........_... <br /> O ,RE <br /> — fgNE TC <br /> i <br /> Yo E EIv r,EHD ( l <br /> ............. <br /> ..... — ----_1 I—.f.. <br /> .................................................................... . <br /> OHNE AGGREb9 ✓ (J <br /> sac 8EO/iAA ID/ �� <br /> city a �v E <br /> OWNCN MAILING AnOREss MO/FFERENT6vm STAT(j� <br /> OY'rrsrAddreas t / 5�� <br /> Adanson:or Care o! (OPM na/) e`E/ ! <br /> Mailing Address Gty <br /> state <br /> Zip <br /> TYPE OF OWNERSIV: I <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY COUNTY AGENCY❑ - STATE AGENCY❑ FED AGENCY❑ <br /> _ 4 FA LITY FILE OTHER❑ <br /> `� oz ` CR059 REf ID <br /> FACILITY ID>X ACCOUNT ID iM 2 aC{'711� <br /> COMPLETETHEFOLLOW/NG BUSINESS FACILITY /.NFORMAT/ON: <br /> 19 this a NEW Business LOCATION or VEHICLE not Previously regulated by the ENVIRONMENTAL HEALTH DIVISION 7 YES ❑ N <br /> Is this an EAISTING Business LOCATION but a NEW TYPE of regulated Business 7 YES ❑ No <br /> ❑uslNEss/FAaurr Nwsc(TuS WILL BE e/E NAYE ON HEALTH PERMIT) 0A <br /> —i <br /> FAQLIIY ADDRESS(fF FAcn/Trl9AMOBlLEFOW UAYrOR FOOD VFWG1EU9E YAIIORE84J ) BIa TE9 BUSINESSPRONE— <br /> CHV/FFACILlrY,9A MOBILE FOOD UMFORF000 VEIYCLE,-fG0MBIy9CRYAQLR€9SGlYIA- <br /> - <br /> / j STATE i zip <br /> A- <br /> BOARD OF SUPERVISOR Dism—T LOCATION COOL• _Heal KEY2 ____� <br /> Mailing Address for Haigh Permil RDIFFERENr6om Fao/lRyAddre" i Altentlon:or Caro Of(optional) ---JJJ <br /> i <br /> Melling Address City STATE ZIP <br /> SIC CODE. <br /> HIRD PARTY BILLING INFORMATION: Comp/eje,%f Billing Party is different from Business Owner Identified above. <br />_ ......... ...... .._. ........_ .............. . . ....... . ... .... _...... . ..... _....._....... ..........._. <br /> Uusm[ss NAYE : .Alton 5 :or Gr Of (opl/ona/J <br /> i vF 5}cJ� rOC I . G�c -467Lac-3 <br /> PHONE <br /> Mailing Addreee <br /> CITY OL aJl I J t J \ Tin zIP <br /> ACCPUNTADORESS for fees and charges OWNER ❑ FACILITY/BUSINESS ❑ THIRD PARTY BILLING ❑ <br /> ILLINC AND COAIPLIANCP;ACKNOWLEDOMiSNT: I, file undersigned Applicant, Certify 1111111 lint the 0D,ner, Operator, or ANlhorited <br /> gen( of (his Business, and I acknowledge that all PERMIT FEES, PENALTIES, C'NYOUC£AfENT CIGIROFS ;Intl/or 110URI.r C11:11(UFS <br /> fsoei8led Wilk t11is operation will he Ililled to ole at the 11d(lress idenlifle(i ahnve 115 the ACC0IINTAD9RFS.S for this Site. I ASO CCr(ify <br /> tat all information provided on this 111plicnlion is tole and correct; 1uNl (lint all regulated 11CtivilieS will Ile performed in <br /> CCnrdance with all appliCoI)I : SAN JOAQ IIN COUNTY OrdinancC C0(ICs and/or Standards andAVATE and/or FEIIHR v. I.; ws Ind <br /> 01 <br /> egulatiens. /// CDNFIDENBTGKRE <br /> / / ,/� [ E P INT <br /> APPLICANT NAME//rJL///`/✓/-J/ 174,e � <br /> TITLE / Lam, DRIVER'S LICENSE <br /> Y IEE <br /> R <br /> Approvod Ely URI" AcwNniafp Dl Igo Pracessing GomPlelod DY P <br /> - <br />