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SAN JOAQUIN COUNTY ♦ PUBLIC HEALTH SERVICES * ENVIRONMENTAL HEALTH DIVISION <br /> 7- FORM! (EHOCIS(IREVISF910102196) <br /> DATE 7-/7-5, MASTERFILE RECORD INFORMATION <br /> 40 q,SHWEDSFCn00-F0RFHDV5IF0M "NEA]ID.N. . .. CASE4 <br /> ...... . . .. <br /> PAYMENT <br /> OWNER FILE <br /> g) <br /> Y <br /> COMPLETE THEFOLL0WlAG BUSINESS OWNER IAFoRmATlov- CHeCKIF OWaggTrEo9DvF <br /> n..-ewi7NEHD <br /> .................... .......................................I.................................................... ..........................I............................................. .... ....I......... 197 ..................... <br /> ....... <br /> JUBUSINess OWNER PHONE L ....:: <br /> NAME ——————————--_.__—_w--.. ————————————————————— <br /> .......First .............M7............................. {est...................................... SAN dEAQW1104 GQWPWV <br /> *f <br /> BUSINESS NAME(if differwat from Owner Name) Soc SEeL4SWQALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> Qt 4-A Le <br /> 0 # <br /> OWNER HOME ADDRESS DRIVER'S LICENSE <br /> city STATE LP <br /> OWNER MAIL NG ADDRESS jfDjFFER_rNr1ieam0ivn4qrAddre= E Attention:or Care of(optional). <br /> *h4W 4- <br /> jig) S'6L-1,721 4±�-ge---bk <br /> Mailing Address Ci <br /> ty Zi <br /> TYPE OFOWNERSHIP' <br /> CORPORATIONINDIVIDUAL 13 PARTNERSHIP 13 LOCAL AGENCY 0 COUNTY AGENCY C3 STATE AGENCY 13 FED AGENCY 1:1 OTHER❑ <br /> FACILITY FILE <br /> . .......... <br /> ..................... <br /> A" L)NT:TD!* ............ <br /> COMPL&ETHEFOLLOWING BUSINESS FACILITY INFORMATION. — — YES El No <br /> Is this a NEw Business LOCATION or VEHICLE not previousty regulated by the ENVIRONMENTAL HEALTH DIVISION? <br /> Is this an EMST]ING Business LOCA-nON but a NEW TYPE of regulated Business ? YES 13 No 0-' <br /> BUSINESSJFACIUTY N (THIPS VALL BE THE NAME ON HEALTH PERMIT) <br /> L <br /> SLATE# BUSINESS PHONE <br /> i FAciuTy AD13RESS(IFFACJUTYISA MoolLE.FooD UAfiriaR F009VEHIcLeLAsEcommissARY ADDRESS <br /> CITY IFFAcuYfSAfo&ILEFDOUNTORF000Vs�cLetEommssARYADDLESS <br /> STATE zp <br /> 77777T77�7 ::;: j <br /> L........... <br /> " <br /> Mailing Address for Health Perm Z1 jfDIFFEREArrh-omFoct'litrAddress Attention-or Care Of(opl) <br /> zj <br /> ST i <br /> Mailing Addne;;�� <br /> t <br /> 77 <br /> ............... ... ..... <br /> THIRD PARTY BILLING INFORMATION: Complete if Billing Party is different from Business owner Identified above. <br /> .................... ................................. <br /> ..................................................................................................... .................................I.—I................................ <br /> ................................................ <br /> Attention,or Ca pEonnlJ <br /> BUSINE NAME <br /> Mailing Ads[prePHONEss <br /> STA)AVF <br /> CITY <br /> L(1rL.QUN1t3DA SFfor fees and charges OWNER ❑ FACILITY/BUSINESS ❑ THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1, the undersigned Applicant, certify that I am the Owner, Operator, or Authorized <br /> Agent of tfiiS Business, and I acknowledge that all PERM[T FEES, PENALTIES, ENFORCEMENT CHARGES and/or HOURLY CH RGES <br /> certify associated with this operation will be billed to me at the address identified above as the AccouATADDRESS for this site. I ertl <br /> that all information provided on this application is true and correct; and that all regulated activities will be performed i <br /> accordance,k with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or FEDERAL Laws IJ <br /> Regulations. <br /> PL SE PRINT <br /> Wr <br /> APPLICANT NAME SIGNATURE; LAAP � <br /> DRIVER'S LICENSE III: <br /> TITLE <br /> (P"OTOCOPYREQUIRED) <br /> Approved By Gate :.. <br /> ji Completebake - <br /> ...... .. <br />