Laserfiche WebLink
SAN JOAO`_­4 COUNTY ENVIRONMENTAL HEALTH D"ARTMENT <br /> STERFILE RECORD INFORMATION FO <br /> :OWNER ID# �,, � GASB 4FSHADED SECTJONS fpR EHD USE ONLY <br /> OWNER FILE <br /> COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION: <br /> CHECKIF OWNER CURRENTLYONFiLEMTHEHD <br /> PHONE <br /> BUSINESS <br /> OWNER NAME First M! Last <br /> BUSINESS NAME(If different from Owner Name) <br /> <br /> <br /> / <br /> OWNER HOME ADDRESS / 0 IV — / <br /> CITY /�r✓ 0 ' CA STATE ZITS SfIT� <br /> OWNER MAILING ADDRESS (If different from Owner Address) Attention o►Care of <br /> MAILING ADDRESS CITY SLATE ZIP <br /> TYPE OF OWNERSHIP: <br /> 71 <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE �j <br /> FACILITY ID#: CO-OWNER ID#: ACCOUNT ID#: (/ 7L5 <br /> COMPLETE THE FOLLOWING BUSINESS FACILITY INFORMATION. <br /> IS this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO ❑ <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YEs ❑ No ❑ <br /> rBu�SIN �7;7(This will SIESSN�onthe HERMIT) <br /> FACILITY DRESSF�+rn is«MOBILE o�(Nrror rCrLF *th L+IRRARYA❑❑RrSW BUSINESS PHONE <br /> ^Z. MIX, �jV <br /> Suite# <br /> CITY(If FACfLrfY is a MOLE Fc=(JMTor FOOD mCLE use the rnre %sAax Linn STATE. ZIP <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> I MAILING ADDRESS for Health Permit(If DIFFERENT from Facility Address) Attention or Care Of <br /> MAILING ADDRESS CITY STATE ZIP <br /> 4 <br /> SIC CODE: APN It: COMMENT: <br /> �rrnr1611 ADDRFS&for fees and charges: OWNER ❑ FACIUTY1BUSINEESS ❑ <br /> Rrt I INC. AND C OMPL.IANCE ACI{NOWT EDGMF.NT: 1, the undersigned Applicant, certify that I am the Owner, Operator, or Authorized Agent of this <br /> Business, and I acknowledge that all PERMI,x FEES,PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation will be <br /> billed to me at the address identified above as the AccouNT ADng for this site. I also certify that all information provided on this application is true and <br /> correct; and that all regulated activities will be performed in accordance with all applicable SAN JOAQIUIN COIINTY Ordinance Codes and/or Standards <br /> and STATE and/or FEDERAL.Laws and Re ulations. <br /> APPLICANT NAME: SIGNATURE: <br /> Pfease Print <br /> TITLE: DATE DRIVER'S LICENSE# <br /> Approved By Dat Accounting Office Processing Completed By Date <br /> 0 lip <br /> A PROGRAM(EHD 48-02-034 Pink)or WATER SYSTEM(EHD 4"2-003)form txwst be completed for each EHD regulated operation at this I cx=ATIOH except <br /> UST Program(Use SWRCB forms) <br /> EHD 48-02-035 Masterfile Record-Green <br /> 101912003 <br />