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SAN .JOA/ N COUNTY ENVIRONMENTAL HEALTH F 'ARTMENT <br /> MASTERFILE RECORD INFORMATION FORA <br /> SHADED SECTIONS FOR EHD USE ONLY OWNER ID# �/f'J!7(j I9CASE# -� <br /> OWNER FILE <br /> OMPLETE THE FOLLOWING BUSINESS()W CHECK IF OWNER CVRRENR r ON FILE WITH EH D❑ <br /> BUSINESS HO .� �, / <br /> OWNER'S NAME Frst MI Lest 2' � <br /> BUSINESS NAME(If dmvmthmn Owner Nalne) SOC Sec drTax ID# <br /> h / Zo A/ f,✓J/2E S rN (/ I <br /> / <br /> OWNER'S HOME ADDRESS 2 LZI V / <br /> CITY 1414 (' " ��I✓GSTATE I ZIP <br /> OWNER'S MAILING ADDRESS(If dilferenr hum owners Address) Attention were of <br /> MAILING ADDRESS CITY STATE ZIP <br /> TYPE OF OWNERSHIP: <br /> CORPORATION❑ INDMDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTMER❑ <br /> FACILITY FILE Y <br /> FACILITY ID#: CO-OWNERID#: ACCOUNT ID III: J <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(Thi will be fie Bus+N Fon t71e/1EALTH I!MrT, T <br /> FACILITY ADDRESS(If FAetTris a Vt Fa'n UNnor Fawn VEHIOEuse the Crrwrccecv&DCR cI USIN S PHONE <br /> J3!�F 7- 3 �3 (�r-/iAVP CAL✓ALd3 G ✓ -L-7SD;fe# 527-9 90 <br /> CITY(If FACILRYis a MowA F000 UNUM FOOD VEHICLE Use the rnimmRimy G I STATE ZIP <br /> T (K 7 O <br /> BOARD OF SUPERVLSOR D15RlICr LOCATION CODE KEYI KEY2 <br /> MAILING ADDRESS for Health Perm/t(lf D/FFERENTfrom FdO/ItyAddress) Attention orCa a Of <br /> MAILING ADDRESS CITY STATE ZIP <br /> SIC CODE: APN Ji: COMMENT: <br /> dIv'n//Ivr do 2R=5 for fees and charges: OWNER ❑ FACILITY/BUSINESS ❑ <br /> R INr.ANO CnNPI tANCF Ar RNOWI FOGMFNT: 1,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 ArrnUNT ADDRESS 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 /> PPLICANT's AME' SIGNATURE: <br /> Ple9 Print <br /> TITLE: �+ DATE (PHOTOCOPY RF0U1RFD1 <br /> DRIVER'S LICENSE# <br /> ApQ1OVed By C ' Date /` 3 V Aaaunting office Processing Completed By Date <br /> A PROGRAM (EHD 48-02-034 Pink) or WATER SYSTEM (EHD 46-02-003) form Duet be completed for each EHD regulated operation at this <br /> I nCATTnN except UST Program(Use SWRCB forms) <br /> EHD 48-02-035 Masterflle Record Green <br /> 8/19/08 <br />