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SAN JOA-1--IIN COUNTY ENVIRONMENTAL HEALTH DF:?ARTMENT <br /> - STERFILE RECORD INFORMATION FO <br /> SC10NSFDREHDUSE$NIDEONLY OWNER ID# VQ <br /> CASE# <br /> OWNER FILE <br /> CNECKIF OWNER C <br /> OMPLETE rNEFOLLOWING USINESS E NFORMATION' 1/RRENTLYONFILE 19�rMEHD <br /> PHONE: <br /> BUSINESS <br /> OWNER'S NAME Frst M1 Last <br /> BUSINESS NAME(If a erentfram ow er Name) SOc Sec OCTax ID# <br /> G ,—s--s <br /> OWNER'S HOME ADDRESS Z 7 ,5 T� / C I G4L?t� <br /> 7 , <br /> CITY A N V T 4 STATE ZIP a 9 <br /> yy <br /> OWNER'S MAILING ADDRESS (If dilfemntfiromownees Address) Attention orCare of <br /> I MAILING ADDRESS CITY STATE Zip <br />' TYPE OF OWNERSHIP: <br />' CORPORATION❑ INDIVIDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY ElOTHER C1 <br /> FACILITY FILE <br /> FACILITY ID#: CO-OWNER ID#: ACCOUNT ID#: <br /> M=FA97E THE W <br /> I 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 /> h <br /> BUSINESs/FACILITY NA14.p(This will be the&wNESsN4mEon the J1EAL RMIT) <br /> FACIL1l1fADDR ( A��s! ���� ��� the ) BUSINESS PHONE <br /> JS Suite <br /> CITY(If FACILITYis a MOBILE FOOD UenrorOD VEHICLE USe the COMMIS89RY C STA ZIP <br /> a� A C/ <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEYS KEY2 <br /> k <br /> MAILING ADDRESS for Health Permrt(If DIFFEREN7-from FacilWAddress) Attention orcare Of <br /> MAILING ADDRESS CITY STATE ZIP <br /> l SIC CODE: APN#: COMMENT: <br /> I Arr hVr 4nr1QFSf for fees and charges: OWNER ❑ FACILITYIBUSINESS ❑ <br /> I <br /> f Ru I iNr AND compo iANrE Ar_KNnwl FDOmENr: 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 and/or HOURLY CHARGES associated with this Operation will be billed to me at the <br /> I address identified above as the ArrOUNIADDRES 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 /> i FEDERAL Laws and Re ulations. <br /> r PPLICANT'S AME' <br /> SIGNATURE' <br /> Please Print <br /> TITLE. DATE DRIVER'S LICENSE(PHOTOCOPY RFntIjRCn1 <br /> # <br /> Approved Bye. Date, �r] h Accounting Office Processing Completed By Date Ig O <br /> 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 <br /> II OCATION except UST Program(Use SWRCB forms) I <br /> w EHD 48-02-035 Masterfile Record-Gree <br /> 8/19/08 <br />