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SAN JOAr N COUNTY ENVIRONMENTAL HEALTH 17"ARTMENT IVIASTERFILE RECORD INFORMATION FOR 7� SHADEDSEC77ONSFOR EHD.USEONLY =OWNIER CASE# OWNER FILE COMPLETE THE POLLOWINGBUSINESS NFORMATION, CHECKIF OWNER CuRRFN7zr0Xt71.EWrMEHD0 BUSINESS ONE' OWNER'S NAME Fast MI Last BUSINESS NAME(If different from owner Name) f/ rj SOC Sec orTax ID# OWNER'S HOME ADDRESS r/fyG[�vA00tv L /L— f-Al — CITY R u 2� STATE ZIP OWNER'S MAILING ADDRESS(Lf dilTemntfrom Owner's Address) Attention orCare of MAILING ADDRESS CITY STATE ZIP TYPE OF OWNERSHIP: CORPORATION❑ INDIVIDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ FACILITY FILE FACILITY ID#: CO-OWNER ID#: ACCOUNT ID Q Is this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No ❑ Is this an EtasTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ❑ $USINESS/FACILITY NAME is willbe the O n/ Nanrean the HEAL Z1i PER�h1 �� A�7 A6 FACILITY ADDRESS(If Fav is a M061LEFcco UATrorF�V27-fx euseLthlelr +J"";ccavv annRrts) BUSIN PHONE [ 9 v I f4A y /� Suite# 9 Zjy7 Z 7`�U CITY(If FACfLMYls a MosuE FOOD UNrrorFgoD WmcLE use the CDMMicc_ewv f'm) ST S ZIP /0--r BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 MAILING ADDRESS for.Health Permlt(If DIFFERENTfrom FadlityAddrez) Attention orCare Of MAILING ADORESS CITY STATE ZIP SIC CODE: APN#: COMMEW: er-r0r1NrAD=9FS=for fees and charges: OWNER ❑ FACILITY/BUSINESS ❑ 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 ACCOuNTADDRFCC 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 NAMEN SIGNATURE' Please Print TITLE: DATE DRIVER'S LICENSE# (PHOTOCOPY Rr-a"TREn) ! Approved By C1 'r V Date Accounting Office Processing Completed By Date 11 Ls 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 I OCATTAAi except UST Program(Use SWRCB forms) EHD 4"2-035 Masterfile Record-Green 8/19/08