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SAN JOAO$IIN COUNTY ENVIRONMENTAL HEALTH Dc u-mvENT <br /> .ASTERFILE RECORD INFORMATION For, <br /> SHADED SECTIONS FOR EHD USE ONLY OWNER ID# U�DD� CASE# <br /> l�OWNER FILE <br /> COMPLETE THEFOLL W/NGBUSINESS OWN R /NFORMAT/ON.- CHECK/F OWNER CURRENILroNFILEwirHEHO <br /> BUSINESS <br /> OWNER NAME `•'�crJ fP�H2ONE –/�`tet/ F <br /> First M/ Lert .-C 4 1��_���� <br /> BUS S NAME(If dinareat Owner Name) �, $la:Sec OrTaa 1D# <br /> OWNER HOME ADDRESS <br /> Cm STATE ZP �✓� <br /> OWNER MA`LING ADDRESS(N dMara d ftmO KlarAddms) Attention oreare of <br /> �rV <br /> MAILING ADDRESS CITY _ <br /> STATE Zip <br /> TYFEOFOWNEFSHIP: <br /> CORPORATIONOL INDIVIDUAL El PARTNERSHIPLOCAL AGENCY❑ COUNTY AGENCY❑ $TATE AGENCY El FED AGENCYOER❑ <br /> FACILITY FILE <br /> FACILITY ID#: CO-OWNER ID#: <br /> ACCOUNT ID#: <br /> COMPLETE THEFOLLOW/NG BUST ES F CILITY/NFORMAT/ON: <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? YES ❑ NO <br /> BUSINESS/FACILITY NAME(This will be the 6us/NESs Mweon the HEALTH PERMIT) �-�— <br /> FACILITY ADDRESS(t FAMo7is a MbeaeF000(JN/Tor Fano VE ry-use the CA [&g Agt Aaes 35) <br /> ' K 0-�2 �„� ra7 r L.,I BUSINESS PHONE / <br /> =/34L6 <br /> Cm(tFACI w a MOanEF000 UIoTor Foca VENCIE use the COMM 5&MLQ ) $TATE ZIP <br /> BOARD OF SUPERVISORDISTRICT WLLOCATION CODE. KEY1 KEYL <br /> MAILING ADORESS for Health Pef rnjQ f D/FFERENTfrom Fs AM,Addrese) Attention crCare Of <br /> MAILING ADDRESS CITY STATE ]Jp <br /> SIC CopE: t — C' APN#: J 'Li O 09 COMMENT: P <br /> decrn✓Mrdnnaacaforfees and charges: OWNER ❑ FACILITY/BUSINESS <br /> BILLING AND COMPLIANCE ACKN0Wi Tnrs- n ; I, the undersigned Applicant, certify that I am the Owner, Operator, or Authorized Agent of this <br /> Business, and I acknowledge that all PERMLTFEES,PENAL77FS,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation will be <br /> billed to me at the address identified above as the A=LNTAtNNt r for this site. I also certify that all information provided on this application is true <br /> and correct; and that all regulated activities will be performed in accordance with all applic a SAN JOAQU OUNTY Ordinance Colles aasill{uA <br /> Standards and STA and/or FEDERAL Laws and Regulations... / <br /> APPLICANT NAME IGNATURE <br /> Mae,e Prlr t <br /> TITLE; DATE ) i DRIVER'S LICENSE <br /> Approved BY Dale CP fc 3 Accounting Office Processing Completed BY tj V Date ON <br /> A PROGRAM(EHD 48-02-034 Pink) or WATER SYSTEM(EHD 45.02-003)form must be completed for each EHD regulated operation a thi <br /> except UST Program(Use SWRCB forms) s <br /> EHD 48-02-035 <br /> 10/912003 v I I U Masterfile Record-Green <br />