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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DFDARTMENT TERFILE RECORD INFORMATION FOF. SHADED SECTIONS FOR EHD USE ONLY OWNER ID# D CASE# OWNER FILE COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION: CHECKIF OWNER CURRENTLYONFILEwITHEHD❑ BUSINESS HON OWNER'S NAME First MI Last 73 E° BUSINESS NAME If difierentfrom Owner Name) SOC Sec or Tax ID# ,-II ,E� o fN��s C� OWNER'S HOME ADDRESS ?70 tgt SPY A U* CITY , d A 6S-3 $TATE ZIP OWNER'S MAILING ADASS (If d/ff rent from Owners Address) Attention or Care of MAILING ADDRESS CITY STATE ZIP TYPE OF OWNERSHIP: CORPORATION❑ INDMDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ FACILITY FILE FACILITY ID#:D o2 I CO-OWNER ID#: ACCOUNT ID#:e V!a COMPLETE THE FOLLOWING BUSI N ESS FACILITY INFORMATION; IS this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No ❑ Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ❑ BUSINESS/FACILITY N is will be PUSIN N ,E� rPER ) e 24F1qS U/— FACILITY ADDRESS(IfFa arM Fa�(Jty/ror EHiCt�E FICA Mtss A r�ss) USIP7S H ME 7,F,9 J J SJ v,' �/ Z 0 P JY' 4 Street Number Direction Soret Name Street TyDe Suite# CITY(If FACILITY Is a MOBILE FOOD UNITor FOOD VEHICLE use the Commi nar iTY) STATE ZIP i W 0 30 BOARD OF SUPERVISOR DISTRICT FLOCATION CODE TKEY1 KEY2 MAILING ADDRESS for Health Per/lM/t(If DIFFERENT-from FacilityAddress) Attention or Care Of MAILING ADDRESS CITY STATE ZIP SIC CODE: APN#: COMMENT: ACCOUNTADDRESS for fees and charges: OWNER ❑ FACILITY/BUSINESS ❑ BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERMIT FEES,PENALTIES,ENFORCEMENT CHARGES and/Or HOURLY CHARGES associated With this Operation will be billed to me at the address identified above as the ACCOUNTADDRESS for this site. I also certify that all information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or FEDERAL Laws and Regulations. APPLICANT'S NAME: SIGNATURE: Please Print TITLE: DATE DRIVER'S LICENSE# PHOTOCOPY REQUIRED) Approved By /� Date 7+, ;?►,y Accounting Office Processing Completed By Date A PROGRAM {EHD 48-02-034 Pink} or WATER SYSTEM {EHD 46-02-0031 form must be completed for each EHD regulated operation at this LOCATION except UST Program(Use SWRCB forms) EHD 48-02-035 Masterfile Record-Green 8/19/08