BILLING - Laserfiche WebLink

Home Browse Search

SAN.JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM SHADED SECTIONS FOR EHD USE ONLY OWNER ID T_ CASE# OWNER FILE COMPLETE THE FOLLOWING BUSINESS OW N ER INFORMATION: CHECK IF OWNER CURRENTLY ON FILE wirH EHD❑ BUSINESS --f - PHONE: OWNER'S NAME First MI Last BUSINESS NAME(If different from Owner Name) Soc Sec orTax ID# i s�t61S OWNER'S HOME ADDRESS CITY STATE ZIP OWNER'S MAILING ADDRESS (If different from Owner's Address) Attention orCare of O wf C a MAILING ADDRESS CITY ,�- l=fiF SJ{tTE ZIP ! p TYPE OF OWNERSHIP: O CORPORATION INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY OTHER❑ FACILITY FILE FACILITY ID#: CO-OWNER ID#: ACCOUNT ID#: COMPLETE THE FOLLOWING BUSINESS FACILITY INFORMATION: Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES ❑ NO ❑ Is this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ NO ❑ BUSINESS/FACILITY NAME(This will be the Bu /Ness NAMEon the HEALTH PERMIT) ,1. I FACILITY ADDRESS(if FACILITYIS a MOSILEF910D UNITor FOOD VEHICLE se the COMMISSARY ADDRESS) BUSINESS PHONE �LfS lei -- (' suite It CITY(If FAQLITYIs a MOBILE FOOD UNITor FOOD VEHICLE use the COMMISSARY CIN) STATE ZIP car 9s�s- BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 MAILING ADDRESS for Health Perm/t,u D/FFERENrfrom FacilltyAddress) Attention orCare Of aqs 5' Y� MAILING ADDRESS CITY I STATE ZIP SIC CODE: APN#: COMMENT: ACCOUNTADDRESSfor 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 ACCOUNTADDRESS 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: — 1 SIGNATURE Please Print TITLE: DATEDRIVER'S LICENSE# (� /�,7'- /, 35-3 !I-1�-1") PHOTOCOPY REQUIRED) v l `I Approved By Data 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 each EHD regulated operation at this LOCATION except UST Program(Use SWRCB forms) EHD 48-02-035 Masterfile Record-Green 8119/08