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SAN JOA^''IN COUNTY ENVIRONMENTAL HEALTH`nc'�IARTMENT <br /> STERFILE RECORD INFORMATION FOrid <br /> SHADED SECTIONS FOR EHD USE ONLY OwNERID# CASE# <br /> OWNER FILE <br /> COMPLETE E FOLLOWING BUSINESS O NFORMATION' GHECKIF OWNER CtlRRFNTLYONFILEWI7NEHD❑ <br /> BUSINESS PHONE' �9 <br /> OWNER'S NAME1 r <br /> Fast M! Last <br /> BUSINESS NAME(If amrerentfmmowner Name) //VSOC Sec orTax ID <br /> /Ze��n✓p Lv��� <br /> OWNER'S HOME ADDRESS / Q S II/rG���j <br /> CITY G1vrT` �rl� <br /> STATE Z1P <br /> OWNER'S MAILING ADDRESS(If di/ferentf-omOwner's Address) Attention orCare of <br /> MAILING ADDRESS CITY STATE ZIP <br /> TYPE OF OWNERSHIP: <br /> I CORPORATION❑ INDMDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ <br /> k <br /> I FACILITY FILE <br /> f <br /> FACILITY ID#: CO-OWNER ID#: ACCOUNT ID#: <br /> QMPL THEPOLLOWENGBUSik SSFACILMINFoRmAnom <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? YES ❑ NO ❑ <br /> BUSINESS/FACILITY NAME(This will be the BumNFssNaeron[ e I E,&LTH PERMIT) <br /> FACILITY ADDRESS(IfFACrurris a RaCO UNrror/�I iaEuse the CnmmEcaRAar <br /> )RE AnRFcc) USINESS PHONE <br /> n Z-3 Suite# <br /> CITY(If FAGurvis a MOS&E FOOD UNIT or Food VEHxLE use the rnmmigcnav CErv) STATE ZIP rz d <br /> 5 72 / l,�d :1 a/ �f <br /> BOARD OF SUPERVISOR DLsmcr TL;AT10N CODE KEY1 KEY2 <br /> M <br /> MAILING ADDRESS for HealiFJf PerMjt(If DIFFERFNTfrorn FadlityAddreSS) Attention orCare Of <br /> MAILING ADDRESS CITY i STATE ZIP <br /> SIC Cone. APN#: COMMENT: <br /> ArMLINEADDRESSfor fees and charges: OWNER ❑ FACILITYIBUSINESS ❑ <br /> I <br /> RiLLING ANn Cr)MPLIANCF ACKNOWLFDGMFNT; 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 CHARGE'S and/or HOURLY CHARGES associated with this operation will be billed to me at the <br /> F address identified above as the ACCOUAfTADORESS 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 /> ' FEDERAL Laws and Regulations. <br /> t <br /> APPLICANT'S AME' G <br /> Ple"Print <br /> TITLE: DATE DRIVER'S LICENSE# <br /> E <br /> Approved BY - I Date Q !� ® Accounting Office Processing Completed By Date C <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 /> I OCAXTOK except UST Program(Use SWRCB forms) <br /> EHD 48-02-035 Masterfile Record-Green <br /> 8/19/08 <br />