BILLING - Laserfiche WebLink

Home Browse Search

SHADED SECTIONS FOR EHD USE ONLY SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM OWNERID# OVV��(�OS� CASE# OWNER FILE COAfPLETETHEFOLLOW/A(GBUSINESS OWNER 11woRmATlom CHEOKIF OWNER CURRENTLYON FILE wITHEHD9] BUSINESSGUOQ OWNER'S NAME BUSINESS/FA ITY AME (This will be the B S/NES AM on Le w he EALTH PERMIT) — aaeo,n PHONE: �j _l �� L 3 '710/ v I v t First MI BUSINESS PHONE Last BUSINESS E (If differentfrom Owner Nam) G �� , W�— STATE SOC Sec orTax ID # OWNER'S HOME ADDRESS C/- 6 :!bd CIN S)zCbyn =KEY1 ZIP OWNER'S MAILING ADDRESS (If different from Owner's Address) MAILING ADDRESS for Health Permlt(If DIFFERENTfrom Facility Address) Aplention orCa a of y�/� /� I i �a 1 MAILING ADDRESS CITY MAILING ADDRESS CITY Sal ZIP M TYPE OF OWNERSHIP: CORPORATION ❑ INDIVIDUAL ❑ PARTNERSHIP ❑ LOCAL AGENCY ❑ COUNTY AGENCY STATE AGENCY ❑ FED AGENCY OTHER ❑ FACILITY ITT F€LE [ FACILITY ID #: �C�� I / CO-OWNER ID #: ACCOUNT ID #: f��3 113 COMPLETE THEFOLLOWINGBUSINESS FACILITY INFORMATlom 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/FA ITY AME (This will be the B S/NES AM on Le w he EALTH PERMIT) — aaeo,n FACILITY ADDRESS (If FACIL/Tris a MOB/LEFOOD U Tor FOOD VEHICLEuse the COMMISSARY ADDRESS) Street Number Direc6on Street Name Str—t Tv— Suite # BUSINESS PHONE CITY (If FACILITY Is a MOBILE FOOD UNIT or FOOD VEHICLE use the COMMISSARY CITY) STATE ZIP BOARD OF SUPERVISOR DISTRICT LOCATION CODE =KEY1 KEY2 MAILING ADDRESS for Health Permlt(If DIFFERENTfrom Facility Address) Attention orCare Of MAILING ADDRESS CITY STATE ZIP SIC CODE: APN #: COMMENT: ACCOUNTADDRESS for 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 t0 me at the address identified above as the ACCOUNTAODRESS 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 Requlations. APPLICANT'S NAME: 4 C/y SIGNATURE: (� Please Print TITLE: \ l I Z ei- 1 A 67w DATE A it � � PHIVER'S LICENSE # OTOCOPY REQUIRED) II Approved By I Date II Accounting Office Processing Completed By ,/Y//() ////f I I Date -1511 / II 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 8/1 9/08