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SAN JOAQUIN COUNTY IUBLIC HEALTH SERVICES • ENVIRONN ;AL HEALTH DIVISION <br /> ' ZZ FORM (EH001S(REVISED1D131100) <br /> DATE f _J MASTERFILE RECORD INFORMATION <br /> loVEDSM89 GOR EHL?USE aV(_r OWNERID/... . DAPks , <br /> OWNER FILE <br /> CHECK rE OWNER Cuaeexrzrox FILE wnHEHO El <br /> COMPLETE T <br /> OMPLETET.H..—..E..—...F.—..O..—..L..—.L...O—....W—..../—..N....G.....B....U.—...S.—.INESSOI <br /> WNE....R.... /NFORMAT/ON. <br /> ..P..t.n.?..NA..E......`..j.........�............Y.....�.............................. <br /> ........ <br /> ................................................................................... <br /> ........................................................... <br /> NAM ---------r --------- 0� <br /> I <br /> SualWas NAME(If dHrereet/iwnDwner Name) 8DC 8[C I TAM 10/ ; <br /> I <br /> iOWNER HOME AODREPB � <br /> City STATE I ZIP <br /> i <br /> � OWNER MAILING ADDRESS HO/FFERENTIrom Owner Addles+ I <br /> Attention:orcare of (optional) i <br /> I <br /> ' stale • Zip <br /> i <br /> Mailing Address City <br /> i <br /> TYPE OF OWNERSHIP: <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ t1THER❑ <br /> �n FACILITY FILE <br /> FACILITY ID IM- 00`N g CROsd.R F ID M 'I AccouNT Ip <br /> COMPLETETHE.FOLLOW/NG BUSINESS FACILITY INFORMATION.- <br /> hit <br /> NFORMAT/ON. <br /> IS this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DIVISION 7 YES ❑ NO ❑ <br /> Is this en E1STING Business LOCATION but a NEINTYPE of regulated Business 7 YES ❑ No ❑ <br /> I SUSINE.WFACILRV NAME(THIS WILL BE PIE NAME ON HEALTH PERMIT) j <br /> u � <br /> I FACILITY ADnnfeP(1F FAC/L/rYIaAMOBILEFCOe UNrOF FOOD VEIeCLEU6ECOMIa99AR1• OME SuiE� BUBINEaDRbME <br /> �y ti Ch/ 's'4 A-a 4 � <br /> I <br /> CITY IF FAG/LIrYI9AMOBIlEF000 UAYT OR F000 VEMCLEUSE1g9s�aY AOOREBS CITY) i STA�ZM <br /> C � I <br /> BOARD OP SUEERYBIOR DISTRICT Loco ION COME KEA KeY2 <br /> i Mailing Address For fyolim Permit HOIFFERENTIrom Fac//1ty Address Attention:or Care Of(Oplimull <br /> I ; <br /> ISTATE LP <br /> i <br /> Mailing Address City <br /> I <br /> $IC Cosa .i. APNM COMMENT <br /> THIRD PARTY BILLING INFORMATION: Complete if Billing.Party /9 different from BBsinesS.Owner./denflfrBd 9bOVB.......................... <br /> ................................................................................................. ............ ............. P <br /> BUNNEss NAYS Attention:Or ( <br /> Care Of O Honal1 i <br /> : <br /> Malling Addreea PHONE <br /> QTY _ 11 STATE i ZIP <br /> ACI2IUlNEADDRE99 for fees and charges OWNER ❑ FACILITY/BUSINESS ❑ THIRD PARTY BILLING ❑ <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1, the undersigned Applicant, certify Ihal 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 ACCOUNTADDRFSS for this site. I also Certify <br /> that all information Orovided on this apl)lication is true and correct; and that all regulated activities will lie performed in <br /> accordance with all applieablC SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or FEDERAL Laws and <br /> Regulations. <br /> . PLEASE PRINT <br /> APPLICANT NAME SIGNATURE <br /> TITLE ORIVER'S LICENSE 4 <br /> (PHOTOCOPY REQUIRED) <br /> Approved Hy Det. Accaunling OKICe PrOcessinll GOmpidta EI I'. .. Data <br />