BILLING - Laserfiche WebLink

Home Browse Search

SAN JOAC-"N COUNTY ENVIRONMENTAL HEALTH P 'ARTMENT iITASTERFILE RECORD INFORMATION FOLIO( SHADED SECTIONS FOR EHD USE ONLY "7r CASE# OWNER FILE COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION: CHECK IF OWNER CURRENTLY ON FILE WITH EHD Fj BUSINESS PHONE �J_ p� �� OWNER NAME First MI Last 3 / O BUSINESS NAME(If different from Owner Name) Soc Sec or Tax ID# CITY �3F SToc�TON OWNER HOME ADDRESS CITY T'16- STATE ZIP S ZU OWNER MAILING ADDRESS (If oifferent faun Owner Address) Attention or Care 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#: PeN CO-OWNER ID#: ACCOUNT ID COMPLETE THE FOLLOWING BUSINESS FACILITY INFORMATION: IS this a NEW Business LOCATION Of VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO ❑ Is this an ExISTWG Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ❑ BUSINESSIFACILTTY NAME IM;rnll be the BUSINE MaMEon the HEALTH PERMIT) 1:5,L D oil DD S/ FACILITY TV-72 V-7 (I(FAGUrT IsaMoiaE� Dr�r�/9,00 us3 7'N ADDRL.S51 BUSINESS PHONE N /7b /r�x///77 NNi r�� r lTStreet M Suite# mbef CITY(it FAcol to a MOea.EFOoD UNnor FOOD VEwcLEuse the CoMoSSA=Y Cm) STATE ZIP S � BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 MAILING ADDRESS for Health PerrTllt(If DIFFERENTfmm Facility Address) Attention or Care Of MAILING ADDRESS CITY STATE ZIP SIC CODE: APN#: CouuEm: A r`f i'll INT AnnRFS.0 for fees and charges: OWNER ❑ FACILITY/BUSINESS ❑ Bn t tvc ANn Covtrt 1ANCr ACRNnwt.FnCMrNT: L the undersigned Applicant, certify that I am the Owner, Operator, or Authorized Agent of this Business, and 1 acknowledge that all PERMq FEES,PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation will be billed tome at the address identified above as the AccouNrAppimtc 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 JOAQVIN COUNTY Ordinance Codes and/or Standards and STATE and/or FEDFRAL Laws and Reetalations. APPLICANT NAME: SIGNATURE: Please Print TITLE: DATE DRIVER'S LICENSE# Approved By La ,�. Date 3 16,Y Accounting Office Processing Completed By Date A PROGRAM{EHD 48-02-034 Pink)or WATER SYSTEM(EHD 46-02-003)forth must be completed for each EHD regulated operation at this LDCA'DDN except UST Program(Use SWRCB forms) EHD 48-02-035 Masterfile Record-Green 10/9/2003