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SAN JO COUNTY ENVIRONMENTAL HEALTH ARTMENT STERFILE RECORD INFORMATION SHADED SECTIONS FOR EHD USE ONLY OWNER ID# CASE OWNER FILE COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION: CHECK IF OWNER CURRENTLY ON FILE WITH EHD❑ BUSINESS PHONE: OWNER'S NAME First MI Last BUSINESS NAME(If different from Owner Name) SOO Sec or Tax ID# OWNER'S HOME ADDRESS CITY STATE zip OWNER'S MAILING ADDRESS (If different from Owner's 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❑ FACILITY FILE FACILITY ID#: CO-OWNER ID#: ACCOUNT ID#: COMPLETE THE FOLLOWING BUSINESS FACILITY INFORMATION: Is this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES ❑ NO ❑ Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ❑ BUSINESSIFACILITY NAME(This will be the BuslNEss NAmeon the HEALTH PERMIT) FACILITY ADDRESS(If FACILITY is a MOBILE FOOD UNIT or FWD VEHICLE use the COMMISSARY ADDRESS) BUSINESS PHONE Suite# CITY(if FACILn YIs a MoBILEFom UNnor FOOD VEHICLEUSe the COMMISSARY CITY) STATE ZIP BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 MAILING ADDRESS for Health Permlt(If DIFFERENTfrom Facility Address) Attention or Care Of MAILING ADDRESS CITY STATE zip SIC CODE: APN#: COMMENT: ACCOUNT ADDRESS 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 AccoImUng Once Processing Completed By pate 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 LOCATION except UST Program(Use SWRCB forms) EHD 48-02-035 Masterfile Record-Green 8/19/08