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SAN JOAO"IN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT OSTERFILE RECORD INFORMATION FA SHADED SECTIONS FOR EHD USE ONLY OWNER ID# �)I IDS �7 t ` l� CASE# OWNER FILE COMPLETE THE FOLLOW/NG BUSINESS OWNER INFORMATION- CHEcKIF OWNER CURRENTLYONFILEwiTHEHD❑ BUSINESS / eo r (0(eS` Kc , PHONE: OWNER'S NAME v First MI Last BUSINESS NAME(If different from Owner Name) Soc Sec orTax ID# OWNER'S HOME ADDRESS L4 03 C Y ) 1�-./ CITY _S zip Z l OWNER'S MAILING ADDRESS (If different from Owner's 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#: :- 2-4n 34f CO-OWNER ID#: ACCOUNT ID#: COMPLETE THEFOLLOW/NGBUSINESS FACILITY INFORMAT/ON: IS this a NEW Business LOCATION Or 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 ❑ BUSINESS/FACILITY NAME(This will be the BUSINESS NAmEon the HEALTH PERMIT) FACILITY ADDRESS(If FACILITYis a MOBILEF000 UNITor FOOD VEHI//CLEUSe the COMMISSARY ADDRESS) BUSINESS PHONE rI W t!(L Vl Girl-(� Suite# tr e Number Direction Street Name St—et Type CITY(If FACILITYIS a MOBILE FOOD UNIT Or FOOD VEHICLE use the COMMISSARY CITY) _ STATE ZIP EBOARDOF SUPERVISOR DISTRICT TL:07CAT170NCOEE KEY1 KEY2 MAILING ADDRESS for Hec'1Ith PerM t(If DIFFERENTfrom Facility Address) Attention or Care Of MAILING ADDRESS CITY STATE zip SIC CODE: APN#: -S 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 will be billed to me at the address identified above as the ACCOUNTADDRESs 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: SIGNATURE: Please Print TITLE: DATE DRIVER'S LICENSE# PHOTOCOPY REQUIRED) Approved By( Data Accounting 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 8119/08