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r <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES • ENVIRON ITAL HEALTH DIVISION <br /> 'i-ss 's6 FORM (EH 0015(REmsED 10/02/98) <br /> DATE �j y - �7 MASTERFILE RECORD INFORMATION <br /> SHAOEDSECT/ONSFOREHDUSEG)YLY OWNER Di 3 CASE# <br /> OWNER FILE <br /> COMPLETE THEFOLLOW/NG BUSINESS OWNER INFORMAT/ON. CHECKiF OWNER CURRENTLYONFILEwn-HEI <br /> .......................................................................................................................................................................................................................................................................................... <br /> BUSINESS OWNER PHONE <br /> NAME -----------------------------: .- <br /> ...................................................................First.......................................!N!..............................................ba?(......................................: <br /> 20`1 -- 5y7 7WO <br /> BUSINESS NAME(If difierent from Owner Name) ? SOC SEC I TAX ID S <br /> S 4v c ,rj 55, G ,,.,k <br /> i OWNER HOME ADDRESS DRIVER'S LICENSE# <br /> ClIty STATE LP <br /> E OWNER MAILING ADDRESS ifD/FFEREIVTfromOwnerAddrsss i Attention:or{C{��areof(optional) <br /> Mailing Address City <br /> Ti <br /> C IL 1 StatA Zip z G/ <br /> TYPE OF OWNERSHIP: <br /> T'U (. <br /> Ccrzr-CRATicN) INN."-DUAL❑ P:VMjr=RSH!P❑ LCCAL AssNcY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE ` <br /> FACILITY ID# � Li: f G CROSS REF ID# ACCOUNT'ID <br /> COMPLETETHEFOLLOW/NG BUSINESS FACILITY INFORMATION.' <br /> Is this a NEw Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DIVISION? YES No ❑ <br /> Is this an E)asnNG Business LOCATION but a NEW TYPE of regulated Business? YES ❑ NO <br /> E BuSINEss1FACILITY NAME(THIS WILL sE THE NAME ON HEALTH PERMIT) <br /> �}o Ck�'6►.i SQA+I�g S (3a,,;1L - (Y�Qn,�rc a gfa�c �, <br /> FAcILRYADDRESS(IFFACIu7YISAMooiLEFooOUANroRF000 VsocLEUSECommssARYADDREAA) SUITE BUSINESS PHONE <br /> 2 0 NOr 10,1 2ol- 5q7- 71oiO <br /> CITY IF FACIUTYISAA/oenPFOOD UMroR FOOD VEMCLE USE COMMISSARY ADDRESS CITY) STATE ZIP <br /> eco. ': CA q S33 <br /> BOARDoFSUPE RVISOR'DISTRICT LOCATIOriCODE :': ICEY1: KEY2 <br /> i Mailing Address for Health Permit ifDIFFEREArrfrom FaciiityAddress Attention:or Care Of(optional) <br /> i Mailing Address City i STATE E ZIP <br /> SIC CODE APN i COMMENT <br /> THIRD PARTY BILLING INFORMATION: Complete if Billing Party is different from Business Owner ident�ed above. <br /> :.......................................................................................................................................... (op 1 <br /> BUSINESS NAME Attention:or Care Of bona/ <br /> C 1 u 0.1-0-n, e��.ra�l a.✓ �a V 1 e- <br /> Mailing a0dress <br /> PHONE 7./Ll <br /> cITY ��o\k� a 5 �T)c ZIP-75 Z 2 T <br /> A=owmiAl DRESS for fees and charges OWNER ❑ FACILITY/BUSINESS ❑ THIRD PARTY BILLING <br /> BILLING AND 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 PERMIT FEES, PENALTIES, E.'VFORCEMENT CHARGES and/or HOURLY CHARGES <br /> associated with this operation will be billed to me at the address identified above as the ACCOCNTADDRESS 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 ATE d/o FED Laws and <br /> Regulations. <br /> PLEASE PRINT <br /> APPLICANT NAME O f�J I ^ L 1_ r Qi N SIGNATURE <br /> TITLE r,'✓,ra yM, _ 'V `!a �Y��S� _ e-11A Fed '' DRIVER'S REQUIREIt <br /> D) r <br /> L TziAc (PHOTOCOPY REQUIRED) <br /> Approved By Date Accounting Office Processing Completed Date <br />