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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT M., ERFILE RECORD INFORMATION FORM _ SHADED SECTIONS FOR EHD USE ONLY OWNERID# CASE# OWNER FILE COMPLETE THEFOLLow/NG BUSINESS OWNER INFORMAT/ON., CHECK/F OWNER CuRRENrcyomciLE wirHEHD❑ BUSINESSN PHO E: OWNER'S NAME ' 1 a - a�-O�e m First MI Last BUSINESSNA E If d' ntntfrom0 ner me) /�,r „I� oc Sec r ID t�I� / /L/'/(//l/,•fes 77 [✓/) OWNER'S HOME ADDRE4SOfa W �I CITY CUl S ZIP OWNER'S MAILING ADDRESS (If differentfrom Owner's Address) Attention crCare of ItrIAILING ADDRESS CITY STATE ZIP TYPE OF OWNERSHIP: CORPORATION❑ INDIVIDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY OTHER❑ FACILITY FILE FACILITY ID ff: CO-OWNER ID#: ACCOUNT ID#: COMPLETE THEFOLLOw/NGBUSINESS FACILITY/NFORMAnom Is this a NEW Business LOCATION Cr 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 BUSIN SS(FACILITY AM (Thl will be a Bu INESS Na on th HEALTH PERMIT) FACILTY ADDRESS(If FAC&u iso oe2e Feon UNIT.,F`eo/q/VENWLLLEE/�U$e the COMMISSARY ADDRESS BUSINESS PHONE 11,11. Drech� v fl& Ir Suite# j� CITY(I A I aMosn.EFOOD UNrror FOOD VEH/cLe use the COMMISSARY CI rY) STATE/1n ZIP NnBOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 /V,,y-I KEY2 MAILING ADDRESS for Health Per?Tff(If D/FFERENTfrom Fac/1/tyAddross) Attention or Cara Of MAILINGADDRESS CIN STATE ZIP SIC CODE: APN#: COMMENT: ACCOUNTADDRESS 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 WIII be billed to me at the address identified above as the ACCOUNT ADDRESS 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: A&ei vellv SIGNATURE: P/ease Print n TITLE: DATE DRIC JPHOTOCOPY REQUIRED Approved ay Oete AccocnOng Office Processing Completed By Date 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