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SANJOA COUNTY RECORD INFORMATION FORS ENVIRONMENTAL HEALTH DEP TMENT f SHADED SECTIONS FOREHD USE ONLY OWNER ID# /r1� O/�� Of O, V/,U CASE# lJ OWNER FILE COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION: CHECK IF OWNER CURRENTLY ON FILE WITH EHD BUSINESS PHONE: OWNER'S NAME First I MI Last IL7V �I CJZ z} O BUSINESS NAME(If different from Owner Name) Soc Sec or Tax ID# M2r. iL'alN TiJVJC-r OWNER'S HOME ADDRESS r o JQ k �6 CITY DQ N `I ST TES ZIP OWNER'S MAILING ADDRESS (if different from Owner's Address) Attention or Care of U !/ MAILING ADDRESS CITY STATE ZIP TYPE OF OWNERSHIP: CORPORATION Z INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY OTHER❑ FACILITY FILE FACILITY ID#: — CO-OWNER ID#: ACCOUNT ID#: / COMPLETE THE FOLLOWING BUSINESS FACILITY INFORMATION: C F(L( p (D q{66 b`' 3 Is this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES Ly NO ❑ Is this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ NO BUSINESS/FACILITY NAME(This will bethe aUSINESS NAME On tha EALTH PERMIT In Pl � C ah+ ceV'e — o� o ��ocl!+onl — t# gZ� (5 FACILITY ADDRESS(If FACILITY is a MOBILE FOOD UNITor F000 VEHICLE use the COMMISSARY ADDRESS) BUSINESS PHONE -73L-( W 11Shft, Q Ave . (bb2)28((-OZ£�U Sufe# CITY(If FAciuI 15 Mos LEFOOp UryITOiF000 VEHICLE Use the COMMISSARY CITYI STAT? ZIP ^ �20� BOARD OF SUPERVISOR DISTRICT Iv LOCATION(MODE KEY1 /`/ KEY2 Litt ol MAILING ADDRESS for Health Pennit(If DI 7F Tfrom Facility AOddress Attention or Care Of V e 1Jj 3(J[_J MAILING ADDRESS CITY I O,e Nl \/ STATE SIC CODE: ul 13 l/� APN#• 133 Zoo t/o COMMENT: 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 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 2 t I Date r1 `� 1 Accounting Office Processing Completed By Oale A PROGRAM(EHD 488-02-034 Pink)or WATERSYSTEM(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