Laserfiche WebLink
SAN JOAC.«COUNTY ENVIRONMENTAL HEALTH VRTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> SHADED SECTIONSFOR EHD USE ONLY OWNER ID# I p?J J)[)I S.�_--G CASE# <br /> OWNER FILE <br /> COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION: CHECK IF OWNER CURRENTLY ON FILE KITH EHD <br /> BUSINESS D V 14 G t^ PHONE <br /> OWNER NAME Lt-� SZgt� <br /> First MI Lasf <br /> BUSINESS NAME(It different eom Owner Name) Soc Sec or Tax ID# <br /> OWNER HOME ADDRESS <br /> CITY STATE ZIP <br /> OWNER MAILING ADDRESS (If different from Owner Address) Attention or Care of <br /> MAILING ADDRESS CITY STATE ZIP <br /> TYPE OF OWNERSHIP: <br /> CORPORATION 13 INDIVIDUAL 13 PARTNERSHIP❑ LOCAL AGENCY❑ COUNTYAGENCY❑ STATE AGENCY❑ FED AGENCY 1-1 OTHER❑ <br /> 5 FACILITY FILE <br /> FACILIrvID#: a CO-OWNER ID#: ACcOUrvTID#: f�1��TJ J'3�a <br /> COMPLETE THE FOLLOWING BUSINESS FACILITY INFORMATION: <br /> IS this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES�zk NO ❑ <br /> Is this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ NO ❑ <br /> BUSINESS/FACILITY NAME(This-jibe Ne &NEss NAlueon HEALTH PERMIT) <br /> GI G S'La.014 <br /> FACILITY ADDRESS(IfFAcruTYls a MOBILE FOOD Umror FWD V/EHiCLEuse the(-.nM•ccnRY ADDRESS) BUSINESS PHONE <br /> T� �y <br /> Suite# <br /> CITY(if FADIL Ty x a Mowtz FOOD UNDor FOOD VEHICLE use the CnuuissARY Cm( STATE ZIP <br /> -::Soo�fv- C,9 :�-?SZa? <br /> BOARD OF SUPERVISOR DISTRICT u ,;t_ LOCATION CODE Sz� KEV1 KEY2 <br /> MAILINGADDRESS/Or Ifealfh Peri itof DIFFERENT(rom Facilily Address) Attention or Care Of <br /> MAILING ADDRESS CITY —7-7 L` p' STATE ZIP <br /> SIC CODE: APN#: Q L { �1 �p COMIneNT: <br /> ACCOUNT-ADDRESS-for fees and charges: OWNER ❑ FACILITYIBUSINESS14 <br /> R11 I G AND CGNIPI IANCF ACHN0W1 Fn MFNr: 1, the undersigned Applicant, certify (hat 1 Rat the Owner, Operator, or eluthorited lRefif of this <br /> hasiness, mal 1 acknowledge that all PENANr Fiats, !'r:N:U.]'u::Y, ENI'l NCLAILAIT CII:IRIili.t mil/or H(HIHLY C11:I8(Xv assoclided will' (his OPe1110e11 will be <br /> billed to me at the address idenlllled above as the ACCOUNT ell2ax a for this site. 1 also certify(11:11 I'll hJbrnu lon provided on this appllcaNml Is true and <br /> correct; and that all regulated activities will be perfumed In accordance with all aaplicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards <br /> and STATE:and/or rEDERAI.1-aws and Re'ul:dimis. <br /> APPLICANT NAME: SIGNATURE: <br /> Please Print <br /> TITLE: DATE DRIVER'S LICENSE# <br /> lPHOTOroPY REQUIRED) <br /> Approved By Dale Accounting Office Processing Completed By Dalo 9 ' <br /> A PROGRAM(EHD 4M2-034 Pink)or WATER SYSTEM(EHD 46-02-003)form DlllSJ be completed for each EHD regulated operation at this I OC.ATION except <br /> UST Program(Use SWRCB forms) <br /> EHD 48-02-035 Masterfile Record-Green <br /> 10/9/2003 <br />