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SAN JOA COUNTY ENVIRONMENTAL HEALTH D RTMENT <br /> TERFILE RECORD INFORMATION FOi <br /> CASE# <br /> SHADED SECTIONS FOR EHD USE ONLY OWNER ID# <br /> OWNER FILE <br /> CHECK IF OWNER CURRENRYON FILE WITH EHD <br /> COMPLETE THE FOLLOWING BUSINESS OW NER INFORMATION: <br /> PHONE: <br /> BUSINESS <br /> OWNER'S NAMEFast Mt Last <br /> r V `'� Soc Sec orTax ID# r'L(� 0 ( -' L r7 <br /> BUSINESS NAME(If ditfen=nt(rom Owner Name) OM CQ� P l <br /> t �o I/ �o <br /> OWNER'S HOME ADDRESS �fv � �Len�2o � � E zlP � <br /> CITY w l `C <br /> I/�I b <br /> I Attention orCare of <br /> OWNEWSMAILING ADDRESS <br /> / RJ(if <br /> rd/ �ifferentfmmowner's Address) /JAG/ r <br /> 055 G M`A �� S�� ZIP- l I �J <br /> MAILING ADDRESS CITY P I QOM r-{� <br /> TYPE OF OWNERSHIP: V OTHER❑ <br /> STATE AGENCY C1FED AGENCY <br /> CORPORATION 6 INDIVIDUAL PARTNERSHIP❑ LOCAL AGENCY C1COUNTY AGENCY El ❑ <br /> `Li —� t� FACILITY FILE <br /> t l ACCOUNT ID#: <br /> CO-OWNER ID#: <br /> FACILITY ID#: <br /> COMPLETE THE FOLLOWING BUSINESS FACILITY INFORMATION: <br /> FF�Acww <br /> EW Business LOCATION or VEHICLE not previously regulated by the ENyIRDNMENTAL HEALTH DEPARTMENT? <br /> YES No ❑ <br /> EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ <br /> No <br /> BUSINESS/FACILITY NAM^ClsAwillthe pE$/sAfaMr nthe MEALIFi PERMIT) W4rek6V� <br /> Cy!mss (O. , /Jl� lr I�e Son�rt, <br /> BUSINESS PHONE <br /> ADDRESS(If FAaurris a AfoeltEFciro UNnor FOJD✓ I MI55^av AooaESS) r� n{•fl S�JIrzrCT 1� Suite# <br /> Street Number Direction Sheet Name <br /> STATE ZIP <br /> CITY(If FACILMOM,,YIe MOM,,F000 UNIT or F000 VEHICLE use the COMMISSARY Cm) <br /> S <br /> 2 L r�/.. C' KEY1 KEY2 <br /> BOARD OF SUPERVISOR DISTRICT DD S LOCATION CODE ���- <br /> MAILING ADDR SS for H2B/r/I Permlr(If DIfFERENTfrom FaCilltyAddreSS) <br /> Attention orCare Of <br /> STA /1 71PC <br /> MAILING ADDRESS CIN�� Ute-no.� I n rI <br /> SIC CODE: 8 l l APN#: "2/)el L( L1 b Z v COMMENT: ��.. <br /> ACCDUIVTADDRESS for fees and charges: E]OWNER FACILITYIBUSINESS k <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the Undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and <br /> I acknowledge that all PERMIT FEES,PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this Operation will be billed to me at the <br /> 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 <br /> all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or <br /> FEDERAL Laws and Regulations. <br /> SIGNATURE: <br /> APPLICANT'S NAME: <br /> Please Print DRIVER'S LICENSE# <br /> TITLE: DATE PHOTOCOPY RE UIRED <br /> Approved BY ('1 Date 2. 1 Accounting Office Processing Completed By Date <br /> A PROGRAM {EHD 48-02-034 Pink} or WATER SYSTEM (EHD 46-02-003} form must be completed for each EHD regulated operation at this <br /> LOCATION except UST Program(Use SWRCB forms) Masterfile Record-Green <br /> EHD 48-02-035 <br /> 11/27/07 <br />