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SAN J04^4IN COUNTY ENVIRONMENTAL HEALTH r-PARTMENT <br />' ASTERFILE RECORD INFORMATION F&A <br />! SHADED SECAONS FOR END USE ONLY OWNER ID# D� C CASE# <br /> k <br /> OWNER FILE <br /> I CojifpLE7-E THE FOLLOWINGUSINESS W NFORMATION' ChECtrrF OWNER CURREMzronFrtEwrnsrEHD❑ <br /> BUSINESS P OlN 7&0 b <br /> OWNER'S NAME First MI Last / /` <br /> BUSINESS NAME(If differentrromowner Name) SOC Sec OrTax ID# <br /> CITY v T <br /> OWNER'S HOME ADDRESS 3 Dky/1!/r NT <br /> CITY O STATE ZIP 3 <br /> OWNERS MAILING ADDRESS (If differentfrom Owner's Address) Attention orCare of <br />€ MAILING ADDRESS CITY STATE ZIP <br /> h <br /> TYPE OF OWNERSHIP: <br /> CORPORATION❑ INDIVIDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ <br /> i FACILITY FILE <br /> t ,[y <br /> i FACILITY ID#: CO-OWNER ID#: ACCOUNT ID#:!/� LIU <br /> L M rHE M 10 W-r <br /> IS this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL!HEALTH DEPARTMENT? YES ❑ NO ❑ <br /> I <br /> Is this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ NO ❑ <br /> BUSINESs/FACILrry NAME(This will be the BusrNmWAUKEonnthe HEALTH PER <br /> i FACILITY ADDRESS(If FA=rrYis a AkWLEFCCD L6rurr�orr Faao Vt�rraEuse the rr,MM,ccaoy Arr,�Fcc) BUSINESS PHONE <br /> Z'00. <br /> 0'0'q i/ Suite# <br /> CITY(If FActUTYis a MOBfLE F60D UNITor FOOD VEHICLE use the Commtssaay Crry) STAB ZIP <br /> i <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE 7KEY1 Jl�v KEY2 <br /> MAILING ADDRESS for Health Permrt(If DmFERENTfrom FadlityAddrnss) Attention orCare Of <br /> MAILING ADDRESS CITY STATE ZIP <br /> l <br /> SIC Gone: APN#: commrEwn <br /> ACC01 fNT-4LWRESC for fees and Charges: OWNER ❑ FACILITY/BUSINESS ❑ <br /> Rii i ING AND COMPLIANCH Ar-KNOWLEnGMENT: I,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 andlor HOURLY CHARGES associated with this operation will be billed to me at the <br /> address identified above as the ACCOUNT ADDRESS for this site. I also certify that all information provided on this application is true and correct;and that <br /> I 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 /> APPLICANT'S NM SIGNATURE: <br /> Please Print <br /> TITLE: - DATE DRIVER'S LICENSE# <br /> (PIj=OPY REQUIRED) <br /> Approved By t Date ZZ Aacountlng Office Processing Completed By Date ►�! <br /> A PROGRAM {END 48-02-034 Pink} Or WATER SYSTEM {END 46-02-003} form must be completed for each END regulated operation at this <br /> I OCSTION except UST Program(Use SWRCB forms) <br /> EHD 48-02-035 Masterfile Record-Green <br /> 8/19/08 <br />