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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT STERFILE RECORD INFORMATION For SHADED SECTIONS FOR EHD USE ONLY OWNER ID# iCylr b..//9il J(y!l_/Og CASE# v OWNER FILE COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION; CHEcK7F OWNER CuRRENTLr oN mE wrrN EHD❑ BUSINESS PHONE: OWNER'S NAME - , Firs( MI Last BUSINESS NAME(If different from Owner Name) SOC Sec OrTax ID# OWNER'S HOME ADDRESS 13 1{ V CITY nu[ZIP / OWNER'S MAILING ADD ESS (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 G( g j J t-+-I gC) jLf FACItW1D,#:�" jt�p'21�' 9P CO-OWNERID#: ACCOUNT ID#:$�t COMPLETE THE FOLLOWING B U S I N ESS FACI LITY INFORMATION: Is this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES NO ❑ Is this an ExISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ NO BUSINESS/FACILITY NAME(This will be the eusrrvessNAlvE on the HEAL P RMI7 FACILITY ADDRESS(If FAacmisa 119caILEFmD ND-or V =use the COMMI—RY AOOREss) BUSINESS PHONE -7 l airrh�l o� Street Number Direction Street Name Street T S.Re# CITY(if FAclums a MOBILE FOOD UNIT or FOOD VESICLE use the ComrniSSn YCm) STATE ZIP _ 62d BOARD OF SUPERVISOR DISTRICT LOCATION CODE GS KEY") KEY2 MAILING ADDRESS for Health Perr»rt(tf DIFFERENTfrom FadlltyAddress) Attention Care Of MAILING ADDRESS CITY STAT ZIP SIC CODE: APN#: 0 D COMMENT: �CCOUNTADDRESS for fees and charges: OWNER ❑ FACILITY/BUSINESS ❑ BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,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 ACCOUNTAODRESS for this site. I also certify that all information provided on this application is true and correct; and that all regulated activities will be perfonned in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or FEDERAL Laws and Regulations. APPLICANT'S NAME: pan / SIGNATURE Rleas h[ 02-7 Q� TITLE: DATE DRIVER'S LICENSE# PHOTOCOPY REQUIRED) Approved By Date V Accounting Office Processing Completed By Date / A PROGRAM {EHD 48-02-034 Pink) or WATER SYSTEM {EHD 46-02-0031 form must be completed for each EHD regulated operation at this LOCATION except UST Program(Use SWRCB forms) EHD 48-02-035 Masterfile Record Green 8/19/08