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SAN JOA'-'-'IN COUNTY ENWRON*ENTAL HEALTH r—DARTMENT ��. ASTERFILE RECORD INFORMATION FO lk SHADED SEC770NS FOR END USE ONLY OWNER ID# CASE# OWNER FILE COMPLETE THE FOLLOWING BUSINESS OWNER INFO RMATION: CHECx1F OWNERCuRRexTLYorvFrLsmTHEHD BUSINESS G45` \ �� HONE OWNER NAMELast � S —C First M1 BUSINESS NAME(if different from Owner Name) SOLSec �Tax�ID# ' OWNER HOME ADDRESS CITY �� w i. Cant J v, ZIP OWNER MAILING ADDRESS (if different from Owner Address) Attention or Care of MAILING ADDRESS CITY STATE ZIP TYPE OF OWNERSHIP: tz tz CORPORATION INDNiDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ FACILITY FILE 3 FACILITY IO#: CO-OWNER ID#: ACCOUNT ID#; COMPLETE THE FOLLOWING BUSINESS FACILITY INFORMATION: 2 Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO Is this an ExtsTING Business LOCATION but a NEW TYPE of regulated Business? IBES ❑ JNO v T = u F BUSINESSIFACILITY NAME(This will be the Busmess NApE on the HEALTH PERMI } 174 Pao b-a Lv FAcILrrY ADDRESS(If FACILITY is a MoGiLE FFooD UNIT or FOOD VEHICLE use the BUSINESS PHONE {� 7 -L� ` N ame Suite 4Street J�3 `l L ✓�s --- Street Type CITY(If FAClLITYis a MoBlLE FOOD UNIT or FOOD VEIWCLE use the MMMMSAE G" STATE ZIP BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEYt KEY2 MAILING ADDRESS for Health Perfrllt(If AIFFERENT from Facility Address) Attention or Care Of MAILING ADDRESS CITY STATE ZIP SIC CODE: APN#: CoMMENr: for fees and charges- OWNER ❑ FACILITY/BUSINESS : I, the undersigned Applicant, certify that I am the Owner, Operator, or Authorized Agent of this Business, and I acknowledge that all PERuV FEES,PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation will be billed to me at the address identified above as the ACCOUNT ADDRESS 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 COUNT'V Ordinance Codes and/or Standards and STATE and/or FEDERAL Laws and Re ulations. APPLICANT NAME: ��\�( �v �6 SIGNATURE: Please Print TITLE: Q Y DATE 2 , DRNER'S L SE# L � � Approved ByG'✓� Date C/ 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 earh EHD regulated operation at this LOCATION except UST Program(Use SWRCB forms) EHD 48-02-035 Masterfile Record-Green 1019!2003