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SAN JOAIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> WSTERFILE RECORD INFORMATION Foo <br /> SHADED SECTioNSFOR EHD USE ONLY OWNER ID# D 7 <br /> L IF CASE# <br /> OWNER FILE <br /> COMPLETE THE FOLLOWINGBUSINESS OWNER INFORMATION: CHECKIF OWNER CURRENTLYONFILEWITHEHD❑ <br /> BUSINESS JOHIV WI- T-C PHONE: <br /> OWNER'S NAME �'I z06- I-�g8 .9y o0 <br /> First M/ Last <br /> BUSINESS NAME(If different from Owner Name) Soc Sec <br /> , <br /> OWNER'S HOME ADDRESS _703Z S O u19ij S7- <br /> CITY <br /> TCITY \Er__rJ T I <br /> STATEA (I! <br /> ZIP a Q 3 2 <br /> OWNER'S MAILING ADDRESS (If dilferentfromOwner's Address) Attention or Care of I <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#: �a 4 Q <br /> COMPLETE THE FOLLOWING BUSI N ESS FACILITY INFORMATION; <br /> Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO Ig <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES No ❑ <br /> BUSINESS FACILITY NAME(This will be the BusmEssNAmEon the HEALTH PERMIT) <br /> AMC-rnxcA4 PTL9-rVZA16 Fca"zpfnCWT zNC. <br /> FACILITY ADDRESS(If FAcrurris a MoeiLEFooD UNlTOr F000 VEHraEuse the COMMISSARY ADDRESS) BUSINESS PHONE <br /> zq 96 I-oornzs Rb. ( 12 - 2 l�>& <br /> Street Number Direction Street Name Street Tyve Suite# <br /> CITY(If FACILITY Is a MOBILE FOOD UNIT or FOOD VEHICLE use the COMMISSARY CITY) F�CIIA <br /> E ZIP <br /> S-rOCK-TON / s s <br /> BOARD OF SUPERVISOR DIsrRICT6 LOCATION CODE � KEY1 KEY2 <br /> MAILING ADDRESS for Health Permit(If DIFFERENTfrom FacilityAddress) Attention or Care Of <br /> MAILING ADDRESS CITY ^ STATE ZIP <br /> =SICCIIE: APN#: l I (, L 3 COMMENT: <br /> IKU <br /> ACCOUNTADDRESS for fees and charges: OWNER ❑ FACILITY/BUSINESS <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner, Operator,or Authorized Agent of this Business,and <br /> 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 ACCOUNTADDREss 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 /> S t <br /> APPLICANT'S NAME: r vl� C ze--ss SIGNATURE: <br /> Please Print <br /> TITLE: DRIVER'S LICENSE# <br /> �4N A G f-L. DATE 3 -,2q- q PHOTOCOPY REQUIRED) <br /> Approved By v✓l Date '7 C jY) C� Accounting Office Processing Completed By Date �1 <br /> A PROGRAM {EHD 448--02-034 Pink} or WATER SYSTEM {EHD 46-02-003} form must be completed for each EHD regulated`Joperati n at this <br /> LOCATION except UST Program(Use SWRCB forms) <br /> EHD 48-02-035 Masterfile Record-Green <br /> 8/19/08 <br />