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SAH JIOAQUIN COUNTY 6%.OiC HEALTH SERVICES • ENVIR0NII,.,/T,-.,0HEALTH DIVISION <br /> vFORM tEHUO 16(REV1SEe 10131196) <br /> DATA MASTERFILE RECORD INFORMATION <br /> SIADEpS CT NS FO HD USE ON <br /> OWNER FILE <br /> GilECN IF OWNER CURRENTLYON RLEWITN EHq ❑ <br /> COMPLETE THEFOLLOWING BUSINESS OWNERINFORMATION:............................................:......................................................................................... <br /> ... ......................... _. <br /> t BUSINEss OWNER I <br /> • PHONE <br /> NAME € — <br /> -------r"7 ---�--- lql-- ---- tasT------- i <br /> —`.Firs{"."_ ................................................ i <br /> .............I............`...................................................'.......................................................................... <br /> � SOc SEC!TA>t IC 0 i <br /> BUs1NE3S NAME If differym ftm Owner Name , <br /> C r� <br /> j OWNER HOME AUDRE88 <br /> city � $TAS � ZIP <br /> •1 S UC,-ta r�> <br /> OWNER MA Limo ADDRESS 1f171FFE1?ENThnm0wnarAddrmw AHention:orCare of (optional) <br /> j Making Address City i State Zip <br /> TYPE OF OWNER$WP: <br /> CORPORATION❑ INDIVIDUAL 11 PARTNERSHIP 11 LOCAL AGENCY 11COUNTY AGENCY❑ STATE AGENCY❑ Fen AGENCY 11 OTHER❑ <br /> FACILITY FILE qmsoas <br /> - <br /> :: .AOILIT?Y.ID�... UD 'l5b�J <br /> COMPLETETHE.FOLLOW/NG BUSINESS FACILITY INFORMATION: <br /> Is this a NEIN Business LocATION or VEHICLE not previous <br /> regulated by the ENVIRONMENTAL HEALTH DIVISION? YES 11 <br /> No <br /> $9 this an EwsrING Business LocATIoN but a NEW TYPE of regulated Business 7 YES 11 <br /> i <br /> BUSINEss1FACILITY NAME I THIS Witt BE THE NAME ON HEALTH PERMIT) t <br /> -17n Cir <br /> k FACILITY Ai3ORE6S(IFFAC1UlY18A�IOBlIF FOOD I�NrON FOoo VEHwLE USEGOMMIssARy APPREsaJ SUITE# BUsINE88 PHONE <br /> I 3 <br /> i01 U <br /> lyt: �D --------------- <br /> I STATE = ZIP i <br /> i CITYIFFAcllITrl$AMOBlLEFOODUAITORFOODVfhwtrfLA4E s s /1 O <br /> -�C�CfiD� <br /> .6ownb c�9l�eRVliiop Dlsteicfi:.:; <br /> U004 doow,:.i ' lcfxrt <br /> Mailing Address forlf4stlh pormlt IfIJIFFERENTfmm FsclA/yAddrWW j Attention:or Car-Of(opdonxll <br /> Mailing Address City STATE j ZIP <br /> I I <br /> A1PNIt t:iM►e�rTT <br /> THIRD PARTY BILLING INFORMATION: Com�nlete Jf Billing Party !s differentfrofnBusiness Owner Identified above. <br /> ......................................................................................................................................... `` <br /> ••BU81NEas NAME E ,Attention:or Care Of (opUonAQ <br /> _. . <br /> Mailing Address i PHONE <br /> GTy - Tj STATE 1 ZIP E <br /> 1 I I <br /> , ccwNT AagB&4 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 Authorizer! <br /> Agent of this Business, and I acknowledge that all PERMIT FEES, PENALTIES, ENFORCEMENT C,4ARGES and/or HOURLY CIfARGES <br /> associated with this operation will be billed to me at the address identified above as the ACCOUNTADDRESS 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 STATL and/or Fiu)LItAL Laws anti <br /> Regulations. <br /> PLEASE PRINT , <br /> APPLICANT NAME SIGNATURE <br /> TITLE ORIVER'S LICENSE 4 <br /> (PHOTOCOPY REOUIREO)' - <br /> :Applovbd 8y.:. .: Clata AGgvunUng OffiA.06e,~4sInq Q4mA!�t�d RY,_., �, Date <br /> C <br />