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L6, SAN JOAQUIN COUNTY , 'UBLIC HEALTH SERVICES • ENVIRONMT AL HEALTH DIVISION - FORM (EH 001 (RE D10/)2/98} DATE -� �` MASTERFILE RECORD INFORMATION ... I SHWEDSEC770AISFOREW MEOMY 'OWNER 10 i' CASE# i RAWM OWNER FILE COMPLETE THEFOLLOW/NG BUSINESS OWNER INFORMATION.- �EcxiFowNERcuRReRrzroRFueImNEHD ........................................................................................................................................................................................................... ................................................................................ -...BUSINESS OwNER j j ////// :...........NAME ------------------------------------------Fus ..... � Q/I _ .................................................... t................._._.................Mt........................................_....AIRR........._..........................' �Id� O�TZ i Busawss NAME(if different from Owner Name) l.�i 7c�/1rC�I/l IIS OWNER HOME ADDRESS DRNflr8 LICENSE i STATE LP CRY OWERMAIUNGADDRESS HDfFFERENrfrom OwnarAddrom i Attention:werelofibiufi aii 9 Mailing Addrea,CityZip0�� 2 TWEOF(DWNERSXIP: CORPORATION CL INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ FACILITY FILE FACILITYiD# �G - 7,1y-> CROSS REF ID# I I ACCOUNT ID# COMPLETE THEFOLLOW/NG BUSINESS FACILITY /NFORMATION: Is this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DIVISION? YES ❑ NO ❑ Is this an EASTING Business LOCATION but a NEw TYPE of regulated Business? YES) NO ❑ BUSINESSIFACIUTY NAME(THIS WILL BE THE NAME ON HEALTH PERMIT) _ FACILiw ADOREsspFFAMUT ISAMoeae Fo UmrT Fwo VElM:tE COIYSSARYAoG1gw SUITE ` BUSINESS PHOS Trc c CmIFFACIUTISAA( e,EF000 UmroRFooDVeracce COMMISSARYAI Ess CM STATE ! ZIP t BOAHDOFSUPERVSORDISMICT LocATroNCooE KEYI KEY2 Mailing Address forHealtlr Permit WDIFFERENr/rom Fxfluj Address Attention:or Care Of(opeonal) Mailing Address City ! STATE LP SIC CODE APN iCOMMENT: THIRD PARTY BILLING INFORMATION: Completed Billing Party is different from Business Owner Identified above. ...................................................................................................................................................................................................................................................................................... BUSINESa NAME E Attention:wCam Of(optiorMQ Mailing Address '• PRONE QTY STATE 7JP Ah o NTADDR ec for fees and charges OWNER'. FAc[UTY/BUSINESS THIRD PARTY BILLING ❑ BILLING AND COMPLIANCE ACKNOWLEDGMENT. dersigned 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. PLEASE PRINT APPLICANT NAME SIGNATURE TITLE DRIVER'S LICENSE i (PHOTOCOPY REQUIRED) Approved BY Data Accdun6ng Office Processing Completed By '- Data