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SAN JOAQUIN COUNTY • PUBLIC HEALTH SERVICES • ENVIRON IMENTAL HEALTH DIVISION <br /> DATE - " E. SGµ, �.�'.' . _ �1., <br /> MASTERFILE RECORD INFORMATION r Foam {EH ODfsIIRF,naeniorozrs,sl <br /> SKIDEDS C7IONSFOR DU Y awNEla iii <br /> COMPOVMER FILE �a <br /> FOLLOWING BUSINESS OWNER /NFORMAT/ON: ] I CAwr lF OWNER C"R'kmrrLr0N"LEwnNEHD <br /> El <br /> NAM -_-w_ ----_---- --------- PHONE _-» _._ ..._... .-_.. <br /> Bu&NESs Nww(If d/ffaiantPram Dwner Name) h!! --- M j '`-CJ l '�-SV 7, 7671 Z. } <br /> S S0. k SOC SMITAX In# <br /> OWNER HoNEADDRESS <br /> ! tSTATE <br /> � i E <br /> ONNETRMAIUNGADDRESS /fDIF7ERE7VTfwnOwnerAddress <br /> e L + , c Attention:orCare of(vP/idNt1J <br /> T W Nk Z 7Zy►%I g� ar, ,J �Co Gl/oo /I/ <br /> Mailing addna,;.City <br /> Szo <br /> 9ii <br /> TYpE of ONINERgfpP• -_ <br /> CORPORATION INOIVIOIIAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGB#c oSTATE AGE!Ncr❑ FED AGENm❑' <br />' OrlfeR❑ <br /> FACILITY FILE <br /> AtxouNraDa <br /> COMPLETE THE FOLLOWING BUSINESS FACILITY INFORMATION. <br /> Is this a New Business LOCATION or VEHICLE not pre, mmly regulated by the ENVIRONMENTAL HEJILTN 0i1HS10N 7 YES'K No ❑ <br /> { <br /> Is this an EIasTING Business LOCATION but a NEW TYPE of regulated Business'? YES 13NO , <br /> BUSINESSIFACkm NAME(Tm wILL 9ETHE NAME ON HFALTH PERMIT) <br /> Sa 0 i <br />` FA3LnyAoneESS(IFFACILnYISAiIoeaEFOODiAWrawFOWVe�cr� <br /> e� MNn;swR,r I g BUSINEiSS pi <br /> ONE <br /> _ i} 2-0 1- 52F7 7100 <br /> CITY IiFArxnmAA#a9ALFFOOD 0—ORFOWVVMC EUSECgWAMwRrADDREaaCrrxf STATE i ZIP,- -- , <br /> g <br /> C!� s2-01 . <br /> $CiAAD>7fi8UPpttVISORtSTRICI:;? - .: :-,nCiloeitrOo� -:- ': <br /> Mailing Address forNmlinA-Tnt lfDIFFERQVr&t-F,'.'LyAW, Athenllors:or Cara Of foPda►tafJ i <br /> Mailing Address City ! I STATE 21P <br /> . <br /> SIC:CODE APHi COfYElii' <br /> .-..... .... <br /> ..... <br /> THIRD PARTY BILLING INFORMATION: Complete if Billing Party is dit]`erehtfroniBusiness Owner/dentifiedahove. <br /> 8uauess NAMa ;Afton":arCwe Of Apo I-0 <br /> C +�o rctN Fe awl CLV i 0 <br /> Mg[lij2g Aodress -- mow <br /> VP 3&0 <br /> Zr <br /> Cm e.5 STATE z� <br /> ACCOUNT ADDRESS for fees and ChwVes pWNM 0 FACu YMUSINESS 11 THIRD PARTY BILLING a <br /> BILLING AND C0MPLL4VCE ACKNOWLEDGMENT: i, the undersigned Applieaat,certify that ill am the Olmer, Operator, or Authorized <br /> .4gent of this Business, and I acknowledge that all PERWT FRES, PENALTJES, ENFORC�ENT CHARGES and/or HOURLY CHARGES <br /> associated with this operation will be billed to me at the address identified above as the ACcbUNTADD=S for this site. I also certify <br /> that all information provided on this application is true and correct; and that,all 'regulated activities will be performed in <br /> accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and TE d/o FED Laws and <br /> Regulations. i'•� <br /> i PLEASE PRINT { :I <br /> APPLICANT NAME - _I.. SIGNA7llRE <br /> fldUlii <br /> TITLE �AI✓+rrjlll f12 Qi.+ ` R �1}tSf ` jj DRIVER'S LICENSE of <br /> Y �+ F C JIJI PHOTOCOPY REQUIRED! _- <br /> APP!P ay. flats �Acroun8ng[JtfEca_Proeprliig>roi�ipls�sd$y <br /> ..-. .. ...... -..::. - S <br /> si '+ <br />