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` r^ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES . ENVIRON TAL HEALTH DIVISION <br /> FORM (EHU01S(REVISED101=961 <br /> DATE MASTERFILE RECORD INFORMATION `/ 11 �J <br /> OWNERIDK CASE# 1�•1 y"-4 0370 / I <br /> SHADED SECTIONS FOR EHO USE 21-Y LA <br /> V-4 <br /> OWNER FILE <br /> CHECK YF OWNER CURRENTLYON FILE W/1N EHD ❑ <br /> COMPLETETHEFOLLOW/NG BUSINESS OWNER INFORMATION: . <br /> ................................................................................ <br /> .................................. ........................................................................... ....................... <br /> BUSINESS OWNER —_— — HONE <br /> __—__—__ P <br /> NAME �______ __ <br /> FistLest...................................... <br /> .....................................................................at.......................................M!..................................................... SDC SEc/TAX ID# <br /> BUSINESS NAME(IT d� 67t�DWnef Na e) <br /> DRIVER'S LICENSE# <br /> OWNER HOME ADDRESS —/1 <br /> STATE n ZIP J S <br /> City <br /> .9'" Attention:orCare of (optional) <br /> OWNER MAILINGADDRESS ii DIFFERENT"IN' OWnerAddresc <br /> i State Zip <br /> Mailing Address City <br /> TYPE OF OWNERSHIP: <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID S <br /> COMPLETETHEFOLLOWING BUSINESS FACILITY INFORMATION: YES ❑ No ❑ <br /> Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DIVISION? YES ❑ No ❑ <br /> Is this an E)USTING Business LOCATION but a NEW TYPE of regulated Business? <br /> BUSINEss/FACIUW NAME(THIS WILL 9ETHE NAME ON HEALTH PERMIT) <br /> DSUITE III BUSINESS PIIONE <br /> FACILITY ADDRESS(IF FACILITYISAMDBILEFOOO UMTORF VtTecte UsECOM SISSARYA00RE- <br /> �—s �. (9 <br /> STATE LP�S 3 <br /> C4 IF FACILTYIS A MOBILEFOOp UMTOR FooD VEMCLEUSECOMMISSARYADDRESS <br /> BC/1RD OF SUPERVISOR DISTRICT <br /> :t.00A t.'DUE NEYI '- KEIT �� <br /> Attention:or Care Of(optional) <br /> Mailing Address forHm/tll Permit ifolFFERENTfrom FacilayAe"ne'Y <br /> STATE ZIP <br /> Mailing Address City i <br /> rsic Cam APN# <br /> ................................u ........ <br /> ..... .... ... <br /> THIRD PARTY BILLING INFORMATION Complete/f Billing Party /s d.... nt ftnmBuslness Owner /dent e[dI a Ove <br /> BUSINESS NAME .... 1 - L rE---12a11eOn. �LS 1� —,,+t (✓C.VL <br /> .............................._.................... ,✓..CiyJ. -5U '�u orG <br /> I.�C <br /> Mailing Address EIA G l �1 ` VL'"" all Plats a B) 2 <br /> LP� <br /> C�CV✓�-dv�" 1 <br /> Cm S 1 <br /> ,q r�Q TADOREas for fees and charges OWNER ❑ FACILITY/BUSINESS ❑ THIRD PARTY BII11Nti <br /> BILLINGAND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant, certify that I am the Owner, Operator, or Authorized <br /> Agent of this Business, and I acknowledge that all PERVIT FEES, PENALTIES, EIVFORCE.NENT 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. PLEASE PRINT <br /> SIGNATURE <br /> APPLICANT NAME <br /> DRIVER'S LICENSE# <br /> TITLE PHOTOCOPY REQUIRED <br /> qpped ey 0 to ` Accounting Office Processing Completed Date c I <br />