BILLING - Laserfiche WebLink

Home Browse Search

SAN JO, A COUNTY ENVIRONMENTAL HEALTH L ,RTMENT MASTERFILE RECORD INFORMATION FORM SHADED S£cnooFOREHD USE ONLY OWNER ID# E, lF7�� •� -7/ (.J �� CASE# {/O ! ! / OWNER FILE COMPLETE THEFOLLOW/NG BUSINESS OWNER/NFORMATION.' CHECK/F OWNER CURREN7LYONF1LEW1rN EHD❑ BUSINESS �U /'` _F� U_fir�6 PHONE: OWNER'S NAME �- / FirsfI MI Last BUSINESS NAME(If different from Owner Name) Soc Sec or Tax ID# F '- 'y'0 p I ioa - as s� OWNER'S HOME ADDRESS 1 J 50 5 cv A V-d CIN " 1 in r0 TAE ZIP '7 OWNER'S MAILING ADDRESS(if different from Owner's Address) Attention orCare of -J MAILING ADDRESS CITY STATE ZIP TYPEOF OWNERSHIP: CORPORATION El INDIVIDUA PARTNERSHIP❑ LOCAL AGENCY[:1 COUNTY AGENCY F-1 STATE AGENCY❑ FEOAGENCY❑ OTHER❑ FACILITY FILE FACILITY ID M t CO-OWNER ID#: ACCOUNT ID#: r COMPLETE THEFOLLOW/NG BUSINESS FACILITY/NFORMATION. Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES/0 NO ❑ Is this an EXISTING Business LOCATION buta NEW TYPE of regulated Business? YES ❑ NO BUSINESS/FACILITY NAME(This will be the EIUSINE SNAMEOn the HEALTH PERMITY{- lt�i F FACILITY ADDRESS(NFAc/orris a MOSILEFO cUMror Foca VENicLFuse the ComMlssnav AooNEss BUSINESS PHONE ) lal G I�lowkV1 I kQ_"- �� r 310 D CE-`KQ91ji--2-1 Suite# CITY(if FAdLnWs a MDaILEF000 UNIT or F000 VEHtc Euse the CommissMY Ciry STATE zip ! 415 �O BOARD OF SUPERVISOR DISTRICT 0 i LOCATION CODE by l KEY1 KEY2 MAILING ADDRESS for Health PerM&(If D/FFERENTfrom FacilityAddress) Attention orCa a Of E 9r;'O b; rnrs �e e MAILING ADDRESS CITY STATE ZIP SIC CODE: j �'I] 5cx13 APN#: I S 1 COMENT: ACC2UNrADD6E88for fees and charges: OWNER ❑ FACILITY/BUSINESS BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,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 will be billed to me at the address identified above as the ACCOUNTADORESs 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 Codes and/or Standards and STATE and/or FEDERAL Laws and Regulations. { APPLICANT'S NAME: �(� �{7Y 10 5 C�/jcT- I`-, IGNATUREJ()C>. P/ease PHnt TITLE: DATE(J�J L L) _ (PHOTOCOPYREQUIRED Approved By DateLie /b /,r Accounting Once Processing Completed By Data r ? o A PROGRAM{EHD 48-02-034 Pink}or WATER SYSTEM{EHD 46-02-003}form must be completed for each EHD regulated operation at this LOCA/TION except UST Program(Use SW RCB forms) EHD 48-02-035 Masterfile Record-Green 11/27107