BILLING - Laserfiche WebLink

Home Browse Search

SAN JOAN -'N COUNTY ENVIRONMENTAL HEALTH r 'ARTMENT 1WASTERFILE RECORD INFORMATION FOffA SHADED SECTIONS FOR EHD USE ONLY OWNER ID# CASE# OWNER FILE OMPLETE THE FOLLOWING USINESS W NFORMATION' CHECK IF OWNER CURRENTLYON FILE wmfEHD❑ BUSINESS HON ' OWNER'S NAME First MI Last BUSINESS NAME(If ddlereatfiwn Owner Name) SOC Sec OFTax ID At L'ov /iv OWNER'S HOME ADDRESS Z at 1/ xLi L Tsr F ZZ CITY V/v T' FSG ^ STATE ZIP J OWNER'S MAILING ADDRESS (If di/femntfrom Owner's Address) Attention iarCare of MAILING ADDRESS CITY STATE ZIP TYPE OF OWNERSHIP: CORPORATION❑ INDIVIDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ FACILITY FILE FACILITY ID#: CO-OWNER ID#: ACCOUNT ID#: D (� comPLErE THE Fouowiw BUSINESS FACILITY INFORMArION' Is this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO ❑ Is this an ExISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ❑ BUSINESS/FACILITY r ME'I is w`�be the BeSrNessNAarrarl _TER FACILITY ADDRESS(IfFAcan,Yls a AlosaeF�(Mvror Rzn KHT Euse the rrwnr ky Anry /V BUSINESS PHONE 6 zsJ>z 7f 6(V Suite p CITY(if FACIUTris a MOax.E FOOD UNITOr FOOD VEMCE use the rnw.essmyrrrv) STA � ZIP � 7 5337 BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEV2 MAILING ADDRESS for Health Per/flft(If DIFFERENTfronl Fad/ityAddre ) Attention OrCare Of MAILING ADDRESS CITY STATE ZIP SIC CODE: APN#: Co1.eAENi: ArY'nrrA/r dnnvccc for fees and Charges: OWNER ❑ FACILITY/BUSINESS ❑ Ru,iNG AND roNpl IANrF AcRNowl FOGMENT; I,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 A - _O INSS TAnDRFSS 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 Re ulations. APPLICANT'S NAMEa SIGNATUREO Please Pant TITLE: DATE DRIVER'S LICENSE# J Approved By OL Datelo `J L' /, Accounting Office Processing Completed By Date A PROGRAM (EHD 48-0v2`-034 Pink) or WAITER SYSTEM [EHD 46-02-003) form must be completed for each EHD regulated Yoperation at this 1 OCATION except UST Program(Use SWRCB forms) EHD 48-02-035 Masterfile Remrd-Green 8/19/08