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SAN JOA117—�V COUNTY ENVIRONMENTAL HEALTH D--ARTMENT <br /> �iiiiiiiiiiSTERFILE RECORD INFORMATION Fwh <br /> s <br /> SHADED SECTIONS FOR EHD USE ONLY OWNER ID# �D CASE# <br /> OWNER FILE <br /> OMPLETETHE FOLLOWINGBUSINESS OWISERNFORMA7TON' CHECK IF OWNER CURRENIZYONFILEW27HEHD❑ <br /> BUSINESS ` <br /> OWNER'S NAME 9 2 5Z7-q 9j 71 <br /> F.rst Mt Last <br /> BUSINESS NAME(if drffemntfrom owner Name) SOC Sec OrTax ID# <br /> r � � o �✓ G�ir _ Gc.s 1' <br /> OWNER'S HOME ADDRESS 2 <br /> T. <br /> CITY ti✓ G Al u STATE ZIP c <br /> OWNER'S MAILING ADDRESS (If differentfmm Owner's Address) Attention orCare of J <br /> MAILING ADDRESS CITY STATE ZIP <br /> TYPE OF OWNERSHIP: <br /> CORPORATION❑ INDIVIDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID#: IE33n2 CO-OWNER ID#: ACCOUNT ID#: <br /> ,69 <br /> COAfPLEM WEEMLOWME11USINESS FACILITY INFORMATZON.' <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 /> BUSINE55/FACILITY NAM is w be Q B Na+aeon the H LTH PIT)✓ A�O <br /> FACILITY ADDRESS(If FA=rrY IS a lltt79II.EFOW UNrrp r Fay 1/DiiaEuse th ) BUSINESS PHONE <br /> 957wt pirprann V.— T— Suite# <br /> CITY(ff FACIUTYIs a MOS1o UN+T�FOOD VEHrcce use the rOMMIS58BYSL�) STATE; ZIP r <br /> TefA <br /> 3 ,7 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 7 <br /> MAILING ADDRESS fOrHealtll Pel7Tllf'(If DIFFERENTfrom FadlityAddre"W) Attention orCare Of <br /> MAILING ADDRESS CITY STATE zip <br /> SIC CODE: APN#: CoMMENr: <br /> ACIY214Ur Aal]QFCC for fees and charges: OWNER ❑ FACILITY/BUSINESS ❑ <br /> BILLINn AND COMPLIANCE ACKNCWLFOGMFNT: 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 AccOUNTA—RFSS 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 SAH JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or <br /> FEDERAL Laws and Regulations. <br /> PPLICANT'S AME' SIGNATURE- <br /> please Print <br /> TITLE: DATE DRIVER'S LICENSE# <br /> Approved By Apill <br /> Date I 0 L9 Lo Accounting Office processing Completed By Date <br /> 4a ZIT <br /> A PROGRAM {EHD 484- 2-034 Pink} or WATER SYSTEM {EHD 46-02-0031 form mist be completed for each EHD regulated operation at this <br /> I OCATTON except UST Program(Use SWRCB forms) <br /> EHD 48-02-035 Masterfile Record-Green <br /> 8/19/08 <br />