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SAN JOA(,-'-"N COUNTY ENVIRONMENTAL HEALTH PcPARTMENT <br /> ASTERFILE RECORD INFORMATION FO*i <br /> E_SHADED$ECTTONS FOR EHD USE ONLY OWNER ID !J <br /> OWNER FILE <br /> COMPLETE THE FOLLOWWG BUSINESS OWNER INFORMATION: CHEcxlF OWNER CUIr>zENrLroNFfLEmrNEHD <br /> PHONE <br /> FOWNER <br /> SINESS <br /> NAME First M1 Last <br /> SINESS NAME(1f different from Owner Name) <br /> So' <br /> Sec Or Tax ID# <br /> tZ <br /> og <br /> OWNER HOME ADDRESS S/ UO G W t <br /> CITY p i STATE ZIP ��j <br /> OWNER}MAILING ADDRESS (If ifffeerent ` Gfrom !:m., ddres) Attention or Care of <br /> bSTATE ZEP Q U <br /> MAILING ADDRESS CITY <br /> TYPE OF OWNERSHIP: <br /> CORPORATION❑ INDmouAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID#: CO-OINPIER ID#: ACCOUNT ID#: <br /> COMPLETE THE FOLLOWING BUSINESS FACILITY INFORMATION: <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? 1 ES ❑ NO <br /> BUSINESSJFACILITY NAME(This will be the BUSINESS NAME on the HEAL'T'H PERMIT) <br /> f �o�r a d <br /> FACILITY ArS5ESS(if FAcrLm is a MoslLE Foos UNIT or F000 7�cLu a the COMI4SARY AUDREW BUSINESS PHONE <br /> S /a D 1,4Z _ /���J' <br /> Suite# <br /> CITY(If FACILITY Is MMLE FOOD UNIT or Food VEIiICLE use the[:=LUARY MX) STW zip <br /> X 01» L <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE 1EY, <br /> KEY2 <br /> MAILING ADDRESS for Health Permif(If DIFFERENT from Faci tyAddress) Attention or Care Of <br /> i <br /> MAILING ADDRESS CITY STATE ZIP <br /> SIC CODE: APN#: Comm ENT <br /> dt GO,INT,AaaK9s_for fees and charges: OWNER ❑ FACILITYIBUSINESS ❑ <br /> : I, the undersigned Applicant, certify that I am the Owner, Operator, or Authorized Agent of this <br /> Business, and I acknowledge that all PERMV,FEES,PENALTIES,ENFORCEuENT CHARGES and/or HOURLY CHARGES associated with this operation will be <br /> billed to me at the address identified above as the jCCOUNTADDR4ESS for this site. I also certify that all information provided on this application is true and <br /> correct; and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards <br /> and STATE and/or FEDERAL Laws and Regulations. <br /> APPLICANT NAME: SIGNATURE: <br /> Please Print <br /> I <br /> TITLE: DANE DRIVER'S LICENSE# <br /> tPHOTOCQI!Y REQUIRED) <br /> I Approved By �'� Date /1 9 Accounting Office Processing Completed By Date <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 except <br /> UST Program(Use SWRCB forms) <br /> EHD 48-02-035 Masterfile Record-Green <br /> 10/9/2003 <br />