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SAN JOAQUIM COUNTY ENVIRONMENTAL HEALTH DEPORTMENT M,.,rERFILE RE1CORD INFORMATION FORK. SHADED SECTIONS FOR EHD USE ONvv/LY OWNER ID# 0 0 o C) Y OWNER FILE /(J COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION: CHECK IF OWNER CURRENTLY ON FILE wITH EHO�5 BUSINESS PHONE: OWNER'S NAME Zf3K� QLlSo First MI Last BUSINESS NAME(If different from Owner Name) Soc Sec or Tax ID# Ql' lnnLfi"f.l �9 W e K. OWNER'S HOME ADDRESS j'• d J j} k �j 30o CInGVD e/V i x S;h7— LP OWNER'S MAILING ADDRESS (If different rrom Owner's Address) Attention or Care of MAILING ADDRESS CITY STATE zip TYPE OF OWNERSHIP: CORPORATION k INDIVIDUAL❑ PARTNERSHIP El LOCAL AGENCY El COUNTY AGENCY El STATE AGENCY FED AGENCY OTHER❑ FACILITY FILE FACILITY ID#:�� CO-OWNER ID#: ACCOUNT ID#:A)e V&7/1gfj6- COMPLETE THE FOLLOWING BUSINESS FACILITY INFORMATION: I—FrL.; SD d CJS D FIE this a NEW Business LOCATION Or VEHICLE AOT preVIOUBIy regulated by the ENVIRONMENTAL HEALTH YES NO ❑ om.,.er..�.ro 1hm an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ NO BUSINESS/FACILITY NAME(This will be the BusmEss NAMeon the HEALTH PERMIT) AI+n2rl( AvJ TowerS — � w.ar1) CIS , - ylltl� FACILITY ADDRESS(If FACILITY is a MOBILE F000 UNITOr FOOD VEHICLE use the COMMISSARY ADDRESS) BUSINESS PHONE � �7 � UNAIuF CD- Z8 -o2e6 Suite# CITY(IfFAciurYts a MOBILE FOODUwror FOOD VemCLE use the COMMISsn 71) STAIE zip BOARD OF SUPERVISORDISTRICTO6 LOCATIONCODE KEY1 KEY2 MAILING ADDRESS for Health PBrmlt(if IFF`ERRENTfrom Facility Address) Attention or Care Of MAILINGADDRESS CITY ��i V .� STATE i'� -� zip SIC CODE: APN#: 2 ZCOMMENT: ACCOUNTADDRESS 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 andior HOURLY CHARGES associated With this Operation will be billed t0 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 Re ulations. APPLICANT'S NAME: SIGNATURE: Please Print TITLE: DATE DRIVER'S LICENSE# ,/n/ n PHOTOCOPY REQUIRED IL Approved BY �U Deta '1j Z3 I3 Accounting Moe Processing Completed BY 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 LOCATION except UST Program(Use SWRCB forms) EHD 48-02-035 Masterfile Record-Green 8/19/08