Laserfiche WebLink
SHADED SECTIONS FOR EHD USE ONLY <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />OWNER ID# OP)00230q�5 :::]=CASE# <br />OWNER FILE <br />COMPLETE THE FOLLOW/NG BUSINESS OWNER INFORMAT/ON.' CHECK/F OWNER CURRENTLYON FILE w1THEHD❑ <br />BUSINESS <br />OWNER'S NAME <br />YES NO ❑ <br />Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ <br />JC; r S <br />PHONE: <br />17 6) t- %Fa - -7S03 <br />First <br />MI <br />Last <br />BUSINESS NAME (If different from Owner Name) <br />Jco ,, "S X" 5-10 M j <br />fSoc <br /> <br />OWNER'S HOME ADDRESS 6 ;163 U: <br />CITY j,, C,Ct <br />$TATE <br />ft <br />ZIP 7 <br />OWNER'S MAILING ADDRESS (If different from Owner's Address) <br />Attention orCare of <br />MAILING ADDRESS CITY <br />STATE <br />ZIP <br />TYPE OF OWNERSHIP: <br />CORPORATION ❑ INDIVIDUAL X PARTNERSHIP ❑ LOCAL AGENCY ❑ COUNTY AGENCY ❑ STATE AGENCY ❑ FED AGENCY OTHER ❑ <br />FACILITY FILE <br />FACILITY ID #: D �' 2 CO-OWNER ID #: ACCOUNT ID #Af,DD 45 `j/p I <br />COMPLETETHEFOLLOW/NG BUSINESS FACILITY INFORMAT/ON: <br />Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH <br />YES NO ❑ <br />Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ <br />No <br />BUSINESS/FACILITY NAME (T is will be the BUS/NESS NAMEon the HEALTH PERMIT) <br />� tJ i 5 Lf 5 TUr� s <br />FACILITY ADDRESS (If FAC/LITYIs a MOBILEFOOo Umror,Fooc VEHICLEUSe the COMMISSARY ADDRESS) <br />BUSINESS PHONE <br />Suite # <br />CITY (If FACILITY Is a MOBILE FOOD UNIT Or FOOD VEHICLE Use the COMMISSARY CITY) <br />STATE <br />ZIP <br />cl,do s— <br />s' � aL fog <br />cA <br />BOARD OF SUPERVISOR DISTRICT <br />LOCATION CODE <br />KEY1 <br />KEY2 <br />MAILING ADDRESS for �I alth Perm/t(If DIFFERENTfrom Facility Address) <br />Attention orCare Of <br />617G3 L'JAk,1 P <br />J./",5 <br />MAILINGRES CITY <br />-) to � fo:A., <br />STATE ^ <br />c <br />ZIP ' - <br />�5d6 7 <br />SIC CODE: <br />APN #: <br />COMMENT: <br />ACCOUNTADDRESS for fees and charges: OWNER FACILITY/BUSINESS ❑ <br />BILLING AND COMPLIANCE ACKNOWLEDGMENT: I, the undersigned Applicant, certify that I am the Owner, Operator, or Authorized Agent of this Business, and <br />I acknowledge that all PERMIT FEES, PENALTIES, ENFORCEMENT CHARGES and/or HOURLY CHARGES associated With this operation will be billed to me at the <br />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 <br />all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or <br />FEDERAL Laws and Regulations. <br />APPLICANT'S NAME: f � t 7 JL. u' S SIGNATURE:%`' <br />// <br />TITLE: �(�j1£✓ Please Print DATE 3-ag-1C1 DRIVER'S LICENSE# <br /> / <br />Approved By Date Accounting Office Processing Completed By /r) Date <br />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 <br />except UST Program (Use SWRCB forms) <br />EHD 48-02-035 Masterfile Record -Green <br />8/19108 <br />