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SAN JOIN COUNT ENVIRONMENTAL HEALTH DWTMENT <br /> ASTERFILE RECORD INFORMATION FORM <br /> SHADED SECTIONS FOR EHD USE ONLY OWNER ID# CASE# <br /> OWNER FILE <br /> COMPLETE THEFOLLOW/NGBUSINESS OWNER INFORMAPON: CnEcKTF OWNER CURRENTLYONFILEWrTHEHD <br /> BUSINESS PHONE <br /> OWNER NAME Firsf MI Last wOJT D <br /> BUSINE NAME( diffirt Owner IN a) _ n / <br /> OWNER HOME ADDRESS 3 <br /> CITY S - T ZIP (S.;i o <br /> OWNER MAILINGADDRESS(a dWrmdrromOwner Addraas) At --ti <br /> 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#: <br /> OMPLETETHEFOLLOW/NG BUSINESS FACILITY NFORMAT/ON' Illggq''' <br /> ['11 <br /> s this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO La,I <br /> this an EXISTING Business LOCATION but a NEW TYPEg of regulated Business? YES NO El <br /> BUSINESS/FAC NA his M6filt#yEssNANEon<1HEALTH PERMIT) <br /> FACILITYADDRESS(aFAc i a&iax Ao L4Vffor Foos WHX> methernrML%URYADDRFRc) BUSINESS PH NE <br /> c7r-/-7 `fib 3 t3 3� <br /> CITY(RFAciurvis a 11@m FcoctKaror Foca ItWoceuae the= STATE ZIP <br /> CZ!9 <br /> BOARDOF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> MAI LI NG AD DR ESS for Hee///?PermMir DIFFERENT rom taci/_, Atte Care OF <br /> MAILING ADDRESS CITY STATE ZIP <br /> SIC CODE: APN}t: COMMENT: <br /> dr.`r.'n/INTdnnRF.Q4 for fees and charges: OWNER ❑ FACILITY/BUSINESS <br /> Rn L LNC, AND COMPT rANrE Actv •I.EDGME i I, the undersigned Applicant, certify that I am the Owner, Operator, or Authorized Agent of this <br /> Business,and I acknowledge that all PERMrr FEES,PEAWLITES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation will be <br /> billed to me at the address identified above as the AmnnNTAnnRRce for this site. I also certify that all information provided on this application is true <br /> and correct; and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN Courrry Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and R u ti <br /> APPLICANT, A �`�" I O !D � SIGNATURE- i AS <br /> P%=,Ve riid <br /> TITLE: DATE !11,11,pQ� DRIVER•SLICENSE# <br /> Approved BY Date Aocountirlg Office Processing Completed BY <br /> A PROGRAM(EHD 48-02-034 Pink)oT WATER SYSTEM(EHD 46-02-003)form must be completed for each EHD regulated operation at this I()CATION <br /> except UST Program(Use SWRC13 forms) <br /> EHD 48-02-035 Masterfile Record-Green <br /> 101g120O3 <br />