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SAN JOAQI COUNTY ENVIRONMENTAL HEALTH Dr--�RTMENT 11hr,STERFILE REc.r ORD INFORMATION FOR,, SHADED SECTIONS FOR EHD USE ONLY OWNER ID# -7 I CASE# OWNER FILE COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION: CHECK IF OWNER CURRENTLY ON FILE WITH EHD BUSINESS �� /�� I L ) C,> jz CS�j{]✓3r9�j_ J� l- PHONE( OWNER NAME First MI Last `._2-��93d - Y 3/ BUSINESS NAME(If different from Owner Name) Soc Sec or Tax ID# S,_ <4-,j-0 C e��-� T 4,2 tcc--T S-� 5,_ ve., OWNER HOME ADDRESS /j 577 3 / G /2-c5�0(31t t D rt-->= 7n1)c y's 77 CITY c• STATE ZIP `j —3 7 6, OWNER MAILING ADDRESS (If different from Owner Address) Attention or Care of MAILING ADDRESS CITY STATE ZIP TYPE OF OWNERSHIP: CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ FACILITY FILE FACILITY ID#: O 1-,)--7 CO-OWNER ID#: ACCOUNT ID#: bM 31�/Q COMPLETE THE FOLLOWING BUSINESS FACILITY INFORMATION: IS this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES.W No ❑ IS this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ NO BUSINESS/FACILITY NAME(This will be the BUSINESS NAME on the HEALTH PERMIT) I s FACILITY ADDRESS(If FACILITY is a MOBILE FoOD UNIT Or FOOD VEHICLE use the COMMISSARY AooRFss) BUSINESS PHONE 13 �3' l IA/ r/ AStreet ) ,c Number Direction Street Name re Type Suite# �7/ 3 f CITY(If FACILTTY is a MOBILE FOOD UNIT Or FOOD VEHICLE use the roMMissARY Cm) STATE ZIP .-/-),�_,)� C/n i7 S 3 -7BOARD OF SUPERVIsm DISTRICT 00 S LOCATION CODE � G- KEY1 KEY2 MAILING ADDRESS for Health Permit(If D/FFERENT from Facility Address) Attention or Care Of MAILING ADDRESS CITY STATE ZIP SIC CODE: APN#: Q 1 COMMENT: d[`Cn1INT dnnRFSS for fees and charges: OWNER ❑ FACILITY/BUSINESS &n.l.INc AND CompiljANCF. ACKNONyL DGMRNT: 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 will be billed to me at the address identified above as the AccouNTAnnRES,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 SA.N JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or FEDERAL Laws and Re ulations. 172 6 i L I c, ,,'. L f !� /1 mot, J�?_ APPLICANT NAME: SIGNATURE: Please Print TITLE: / �S!/2 L=),/7- DATE /rj,){I & DRIVER'S LICENSE# (PHOTOCOPY REOUIREDI Approved By Cj (// Date Accounting Office Processing Completed By Date p J A PROGRAM{EHD 48-02-034 Pink)or WATER SYSTEM{EHD 46-02-003)form must be completed for aa>;h EHD regulated operation at this LOCATION except UST Program(Use SWRCB forms) EHD 48-02-035 Masterfile Record-Green 10/9/2003