BILLING - Laserfiche WebLink

Home Browse Search

SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Ii,STERFILE RECORD INFORMATION FOh— SwED SECTIONS FOR EHD USE ONLY OWNER ID At 6 CASE# OWNER FILE COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION: CHEcK1F OWNER CuRRENn v oN FztE wrTH EH11D❑ BUSINESS HONE' OWNERS NAME First MI Last BUSINESS NAME(If&Fierenttrom Owner Na ) SOC Sec OrTax ID# r-D ices OWNER'S HOME ADDRESS CITY / OA G STATE ZIP K3 OWNER'S MAILING ADDRESS (If oVierenffrom Owner's Address) Attention arCare of MAILING ADDRESS CITY STATE ZIP TYPE OF OWNERSHIP: CORPORATION❑ INDMDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ FACILITY FILE FACILITY ID#: ©E>L9 / CO-OWNERID#: ACCOUNTID#,fC,3 COMPLETE THE FOLLOWING BUSINESS FACILITY INFORMATION: [1�stlhisa NEW BUSIne55 LOCATION OrVEHICLE not preVIOUSIy regUlated I)yih2 ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO ❑his an ExISTING Business LOCATION but a NEw TYPE of regulated Business? YES ❑ No ❑ BUSINESS/FACILITY NAME(This will be a BuSrnESSNANEon the HEALTH PERMIT) C FACILITY ADDR F Faro l/raror poen Vea se a HI RY ADDR>=c5) BUSINE PHONE 0 TTT ' /q vs�'i/✓ /( tia �1 5 q, Str&t Number i 'n Street N Street T Suite# / CITY(if FActu"ts a ILE FOOD UNIT or D VEHICLE Me the COMNSSARY Crnt ST ZIP J� D S BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEYf KEY2 MAILING ADDRESS for Health Perro%t(If DiFFERENTfrom Fad/ityAddress) Attention or Care Of MAILING ADDRESS CITY STATE ZIP SIC CODE: APN#: CoNMENr: ACCOUNTADDRE5S for fees and Charges: OWNER ❑ FACILITY1BUSINESS ❑ BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that 1 am the Owner,Operator,or Authorized Agent Of this Business,and 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. 1 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: SIGNATURE: Please Print TITLE: DATE DRIVER'S LICENSE At PHOTOCOPY REQUIRED) Approved ey ' Date/ 2/ G Accounting Office Processing Completed By 1�' Date / /J3 A PROGRAM (EHD 48-0 -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 8/19/08