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SAN JOA IN COUNTY ENVIRONMENTAL HEALTH ARTMENT STERFILE RECORD INFORMATION FO SHADED SECTIONS FOR EHD USE ONLY OWNER ID# Qi. 1B y� (y CASE# OWNER FILE COMPLETE THE FOLLOW/NG BUSINESS OW N E R/NFORMyA now, CHECK/F OWNER CURRENR t'ONF1LEW rHEHD❑ BUSINESS /] C-1- P ONE: OWNER'S NAME e— Fest 6 I Last l!l�I O_ — Tj MI BUSI 3S AME(R rent#oml) Ker Name), Soo Sao orTax ID# MZ OWNER'S HOME ADDRESS CITY A ZIP 9-5 OWNER'S MAILING ADDRESS (If different from Owner's Address) Attention orCare of MAILING ADDRESS CITY STATE ZIP TYPE OF OWNERSHIP: CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY OTHER❑ FACILITY FILE FACILITY ID#: e(S3CO-OWNER ID#: ACCOUNT ID#: COMPLETE THE FOLLOW/NG BUSI NESS FACILITY/NFORMAT/ON: IS this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES NO ❑ ncewe.ucuTo Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ❑ BUSINs/F CI TY N E(This will be HIM ss NA.REo the HEALTH PERMIT) Kr 1 t� FACILITY ADDRESS(HFACiurvlsaMOM& FOoDLINiror FOOD VEMCLEuse the COMMMIISSA ADDRESS B USINESS PHONE S ' ' V y Suite N CITY If FACILfn'Is a MOBILE FOOD UN?or FOOD VEHICLE use the COMMISSARY CITY) S�TE ZIP LrOi O\ BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 MAILING ADDRESS for Health Permit(If D/FFERENTfrom FaciiityAddress) Attention orCare Of MAILING ADDRESS CITY STATE ZIP SIC CODE: APN#: COMMENT: ACCOUNTADORESS for fees and charges: OWNER ❑ FACILITY/BUSINESS ❑ BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that 1 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 ACCOUNTADDREss for this site. I also certify that all information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or FEDERAL Laws and Regulations. APPLICANT'S NAME: SIGNATURE: please Print TITLE: DATE DRIVER'S LICENSE# PHOTOCOPY REQUIRED Approved By Date Accounting Mice Proceaaing Completed By Date h A PROGRAM{EHD 48-02-034 Pink)or WATER SYSTEM(EHD 46-)aYY1111�Eorm mmtt be completed for each EHD regulated operation A this LOCATIOlb except UST Program(Use SWRCB forms) EHD 48-02-035 Masterfile Record-Green 8/19108