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�1 SAN JOAQUIN COUNTY'1 �UBLIC HEALTH SERVICES ♦ ENVIRONM�AL HEALTH DIVISION <br /> ��� FORM (EH Ib t5(REVIseD 1Dl02/96) <br /> DATE 11 a' ) / MASTERFILE RECORD INFORMATION / <br /> SHADED SECTIONS FOR EHD USE 0K <br /> OWNER FILE A' <br /> COMPLETE THE FOLLOW/NG BUSINESS OWNER INFORMATION: CHECXIF OWNER CURRENT.YON FILE wnw EHD <br /> ..................................................................................................................................................................................................................................................................................................... <br /> BUSINESS OWNER PHONE <br /> NAME _________________—___--____—________—___ <br /> '...................................................................First.......................................M! ........................Lest...................................... <br /> siness NA : <br /> BuME(If different from Owner Name) <br /> ...................... Soc SEc I TAx ID# <br /> OWNER HOME ADDRESS DRIVER'SLICENSE# <br /> CRY STATE ZIP <br /> OWNER MAILING ADDRESS ifD/FF REEATfrom OwnerAdld��� p Attention:or Care of (optf n # <br /> 2 0 2 t (..ff�011 <br /> Mailing Address City StatA� ' Zip (I .� <br /> TYPE OF OWNERSHIP: (( <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ <br /> �} FACILITY FILE <br /> FACILITY ID#'. A r-t CROSS REF ID# ACCOUNT ID# t '�'F.''''< <br /> COMPLETETHEFOLLOW/NG BUSINESS FACILITY INFORMATION. <br /> Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DIVISION? YES ❑ NO ❑ <br /> Is this an OUSTING Business LOCATION but a NEw TYPE of regulated Business? YES ❑ No ❑ <br /> BUSINESsIFACIDw NAME(THIS WILL BE THE NAME ON HEALTH PERMIT) <br /> FACILITY ADDRESS(/FFACIUTYISA MOSI(EFOOo UMTORF000 VEWCL£USECOMYSSARY ADDRESS) SUnE# /B�U.SINESS Pl10 <br /> CITY FAL/L/ <br /> STA�ETYISA MOBILEFOOOUN/TORFOOO VE/YCLE USECOMMISSARY ADDRESS CITY/ ZIP <br /> n 7 <br /> BOARD4FSUPERVISORDISTRICT-': LOCATONCODE 11 REY1I I II KEYY <br /> Mailing Address forh"Iffi Permit ifDIFFERENTImm FaeililyAddrexv Attention:or Care Of(Oodonal) <br /> i Mailing Address City STATE ZIP <br /> SIC CODE APN# COMYEN[:. <br /> THIRD PARTY BILLING INFORMATION: Completed Billing Party is different from Business Owner/dentfrfed above. <br /> ........................................................................................................................................................................................................ .............................. ......................................................... <br /> BUSINESS NAME y� , ,L / / ntien:Or Ce (Opt%Ona/f <br /> C.7Y/i� -7 <br /> Mailing dress�� pp f PLANE_/l� `L-O� <br /> / 6L / n �(tiLGi l d <br /> Crrr / t.>/XLX fik.s Sr/ `: LP S-7) <br /> AaCDUff-AUOREss for fees and charges OWNER ❑ FACILITY/BUSINESS ❑ (THIRD PARTY BILLING ❑ <br /> BILLING AND COMPLIANCE AcmNoWLEDGMENT: I, the undersigned Applicant, certify that I am the Owner, Operator, or Authorized <br /> Agent of this Business, and I acknowledge that all PERMIT FEES, PENALTIES, ENFORCEMENT CHARGES and/or HOURLY CHARGES <br /> associated with this operation will be billed to me at the address identified above as the ACCOUnTADDREss for this site. I also certify <br /> that all information provided on this application is true and correct; and that all regulated activities will be performed in <br /> accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or FEDERAL, Laws and <br /> Regulations. <br /> PLEASE PRINT <br /> APPLICANTNAME -y L{ SIGNATURE <br /> TITLE / / DRIVER'S LICENSE# <br /> (PHOTOCOPY REQUIRED) <br /> Approved By Data -Accounting:Office Processing Completed BY .Y��., Date �„ �.f^ r--a <br />