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SAN J()-&,rtUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> = STERFILE RECORD INFORMATION FO-j <br /> I <br /> SHADED SECRONSFOR EHD USE ONLY OWNER ID# � CASE# <br /> OWNER FILE <br /> ompi ETE THEFou owrNG B U SI N ESSQWN g RrNFORMATION' CHECKIF OWNER CuRRENnyoskrLEwrrHEHD❑ <br /> BUSINESS HONE: �q <br /> OWNER'S NAME <br /> First M! Last <br /> BUSINESS NAME(I€different fmm Owner Name) SOC Sec orTax ID# <br /> � r <br /> OWNER'S HOME ADDRESS T16 <br /> CITY V /_ f' STATE ZIP <br /> OWNER'$MAILING ADDRESS (If different hpmOwner's Address) Attention orcare of <br /> MAILING ADDRESS CITY STATE ZIP <br /> TYPE OF OWNERSHIP: <br /> CORPORATION❑ INDIVIDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID#: CO-OWNER ID#: ACCOUNT ID#: izz <br /> s <br /> PL LL W N - <br /> Is this a NEW Business LOCATION or VEHICLE not preVlouSly regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No ❑ <br /> 4 <br /> Is this an E)aSTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ❑ <br /> BUSINESS/FACILITY NAME(This will be rssNAm. nye HfrALT p_E�Mrr) <br /> Al FACILITY., (I FAtrLrn is a MaslLEFcro 1lnrrror FOOD urxiaFe thgLa�s) USIN PHONE <br /> } aJ N • ��s ;e 6 9�.r�,rz 7- 9 <br /> Suite# <br /> I CITY(If FACILITYIs a MOBILE FOOD UgrE or FOOD VEHICLE use the rnMNissARY Crrr} STATE ZIP r- �T <br /> ,STc�G o� Glu �.�- Gd <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE ITEYI: KEY2 <br /> MAILING ADDRESS for HeaIHT Permlt(If bIFFERENTfrom FadlltyAddress) Attention DrCare Of <br /> MAILING ADDRESS CITY STATE ZIP <br /> SIC CODE: APII#; $' COMMENr; <br /> 4CC MATT 4DV9EaC for fees and charges: OWNER ❑ FACILITY/BUSINESS ❑ <br /> } RiLI-INC AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and <br /> t 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 /> 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 /> 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 /> APPLrcANT'sAME' SI A RE' <br /> I Please Print <br /> TITLE: !s DATE DRIVER'S LICENSE# <br /> Approved By f Date D77 <br /> Accounting Office Processing Completed By Date '� I <br /> A PROGRAM {EHD 48-02-034 Pink) or WATER SYSTEM {EHD 46-02-003} form must be completed for eacb EHD regulated operation at this <br /> I OC3nnN except UST Program(Use SWRCB forms) <br /> EHD 48-02-035 Masterfile Record-Green <br /> 8/19108 <br />