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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT M,.,.AiTERFILE RECORD INFORMATION FOR... SHADED SECTIONS FOR EHD USE ONLY OWNERID# �� CASE# OWNER FILE COMPLETE THE FOLLOWING BUSINESSOWNERINFORMATION: CHECKIF OWNER CURRENTLY ON FILE WITH EHD BUSINESS 4 �, Q N 2a PHONE OWNER NAME First MI Last BUSINESS NAME(If different from Owner Name) 1 n- Soo SeC Or TaX ID# OWNER HOME ADDRESS 235 -)` CA a OvI J brau CITY I n1 s zip 2tv OWNER MAILING ADDRESS (If different from Owner Address) Attention or Care of MAILING ADDRESS CITY STATE ZIP TYPE OF OWNERSHIP: CORPORATION❑ INDIVIDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ q FACILITY FILE FACILITY ID#: CO.OWNER ID#: ACCOUNT ID#: a DlD 3( y I COMPLETE THE FOLLOWING BUSINESS FACILITY INFORMATION: Is this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES li NO ❑ Is this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES NO ❑ /t BUSINESS/FACILITY NAME(This will be the BUslNEss N"E on the HEALTH PERMIT) ♦ J.. 9MO /1Q to4�� FACILITY ADDRESS IIf FACILITY is a MoaliF FOOD UNIT or FOOD VEHICLE use the❑OMMSSARnn YAarsc) • 1 BUSINESS PHONE CT31) E CInA-der WA4 9 - 000 Suite# CITY(If FACIV� T a MMLE F UMTor FOOD VEHICLE use the Cns:.ssssaY Cm) STAZIP'q5_20 S 4-o V-lv*JS BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 MAILING ADDRESS for Health Perm/t(If DIFFERENT from FacillyAddress) Attention or Care Of MAILING ADDRESS CITY / (J 7 STATE zip SIC CODE: —SZ APN#: 1p� ( p J O COMMEM: ArrnIINTATIDPF—C for fees and charges: OWNER ❑ FACILITY/BUSINESS ❑ BN.LING AND CnMPIUANcE ACxnnwl.FncnfFNT: 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 ACCOUNTADDRFCc 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 Re ulations. APPLICANT NAME: SIGNATURE: Please Print TIRE: DATE DRIVER'S LICENSE# Approved By Date Accounting Office Processing Completed By / Date lr' D 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 I nrATInN except UST Program(Use SWRCB forms) EHD 48-02-035 Masterfile Record-Green 10/9/2003