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SAN JOAP—N COUNTY ENVIRONMENTAL HEALTH D--ARTMENT 4-*erASTERFILE RECORD INFORMATION For SHADED SECTIONS FOR EHD USE ONLY OWNER ID# O YII CASE$ OWNER FILE COMPLETE THE FOLLOWING BUSINESS NFORMATION• CHECKIF OWNER CURRENrc YON FILE wzTHEHD❑ BUSINESS PHONE: OWNER'S NAME Fssr MI Last BUSINESS NAME(If Oferent from Owner Name) SDC SEC orTax ID At G /1/ ` -f /n / OWNER'S HOME ADDRESS Z � G T F CITY I I ■ , r- G STATE ZIP OWNER'S MAILING ADDRESS (If d#?Ee t from Owner's Address) Attention or Care of MAILING ADDRESS CITY STATE ZIP TYPE OF OWNERSHIP; ORPORATION❑ INDIVIDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ FACILITY FILE FACIU7Y ID#: CO-OWNER ID#: ACCOUNT ID#: F Is this a NEW Business LOCATION Or VEHICLE not previously regulated by Che ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO ❑ Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ❑ BUSINESSIFACILITY N BusfNNEssNaveon the HEALTH PERMIT) FACIL]TYADDRESS(IfFAcmpryis a Mlav R)fi UNnor FCW 14 r1a use thee( -Ic±c Ar ") BUSINESS PHONE ��- 13 7 S - • AV AO/L��/� suite It CITY(If FACILn IS a Moene EC FOOD UNnor FOOD VEHICLE use me r0wesssav rrrY) STATE ZIP BOARD OF SUPERVISORR/DIDISTRCf LOCATION CODE KEY'I KEY2 MAILING ADDRESS for Health Permft(If DfFFERENTfrom Faa/ityAddm ) Attention orCare Of MAILING ADDRESS CITY STATE ZIP SIC CODE: APN#:'14 l�, (3 CoMmea r: 4CC0/NT dnnRESS for fees and charges: Applicant, ElFACILITY/BUSINESS ElRII I IN(:ANn rOMPLIGNCF ACNNDWI Fnr.MFNT; 1,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 tome at the address identified above as the ACCO(/Nr ADDRESS 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. PPLICANY SAME' IGNATURE' Nesse Pant TITLE: /� DATE DRIVER'S LICENSE At y7 Approved ay G'' �a Z/O D AaMnUi Office Processing Completed By Data !� A PROGRAM {EHD 48-02-034 Pink} or WATER SYSTEM {EHD 46-02-003} form wast be completed for each EHD regulated operation at this I OCATION except UST Program(Use SWRCB fors) Eno 4802-035 Masterfile Record-Green 8/19/08