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SAN.JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM SHADED SECTIONS FOR EHD USE ONLY OWNER ID At O � C, 7y CASE# V OWNER FILE �J COMPLETE WEFOLLOWING BUSINESS OWNER INFORMATION: CneclrrF OWNER CuRREnn von FrLE wmr EHD❑ BUSINESS f� OWNER'S NAME T . i IC"reo PHONE: Fhst MI Lesf ("J CJ L/ BUSINESS NAME � f (If d erentbnrn OWner Name) SocSec wTaxID# H '\ �,,rl serl.2�� SSO- y�=39'ls OWNER'S HOME ADDRESS /' CITY /) c 7 Z as Q. !'�'/ q-r7'e s d 7.JP 5-3 6 OWNER'S MAILING ADDRESS (If d//1&eothwn OWner's Address) Attention orcare of MAILING ADDRESS CITY STATE ZIP TYPE OF OWNERSHIP: CORPORATION❑ INDMDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ �i FACILITY FILE FACILITY ID#: GU�tIp GO-OWNER ID#: ACCOUNTID#: 3 COMPLETE THE FOLLOWING BUSINESS FACILITY INFORMATION: Is this a N7EwBusiness LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES NOIs this anNG Business LOCA but a NEW TYPE of regulated Business? YES ❑ No ❑ BUSINF,SS ACDrrY NAME(This will be the B N,we n the HEALTH PERMin N ✓ �� /1�L' G2 5ery/, FACILITY ADDRESS(If FAQtrrria a MME FOOD MTOr fWO VEwoEDse the Cawresmar AODRE55) BUSINESS PHONE 2 LN2 Leis . `Paer5d,? st'retNam Suite# (.2D9)87z_ CITY(HFAUa 0 a MOB"FOOD UMTOr FOOD VEwcaeuse the gmesSARY CITY l Paf-F� s C n SGS Z�`15363 BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEYG MAILING ADDRESS for Health Permft(If DIFFERENTfrom FaCiIOAddress) Attention or Care Of Sane MAILING ADDRESS CITY STATE Zip SIC CODE: APN#: COMMENT: ACX-UATAQPffM 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 WIII 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 COUNTY Ordinance C an /or Standards and STATE and/or FEDERAL Laws and Regulations. I APPLICANT'S NAME: /dl �GLrl-0 SIGNATURE: Gleasr Print TITLE: © r DATE 3/ DRIVER'S LICENSE# PHOTOCOPY REQUIRED) Approved By Date Accounting Office Processing Completed By Dace A PROGRAM {EHD 48-02-034 Pink} or WATER SYSTEM {EHD 46-02-0031 form must be completed for each EHD regulated operation at this LOCATION except UST Program(Use SWRCB forms) EMD 48-02-035 8/19/08 Masterfile Record-Green