BILLING - Laserfiche WebLink

Home Browse Search

SAN JOAO'"N COUNTY ENVIRONMENTAL HEALTH V-4ARTMENT STERFILE RECORD INFORMATION FO�"` - . SHADED SECTIONS FOR END USE ONLY OWNER ID# CASE# OWNER FILE COMPLETETHEFOLLOWING BUSINESS OWNER INFORMATION: CHeCKlF OWNERGuRRENTLYONFTLEWlT1iEHD BUSINESS PHO E OWNER NAME First MI Last BUSINESS NAME(if different from Owner Name) SOC Sec.Or Tax ID# VD_ M OWNER HOME ADDRE4 Z 50 0 h/AP t ]_ CITY S D c ALTO/r STATE ZIP Sid OWNE=R MAILING ADDRESS (if different from Owner Address) Attention or Care of MAILING ADDRESS CITY STATE ZIP I TYPE OF OWNERSHIP: k t CORPORATION❑ wnmDUAL El PARTNERSHIP❑ LOCAL AGENCY❑ COUNTYAGENCY❑ STATE AGENCY E] FED AGENCY❑ OTHER❑ t = FACILITY FILE FACILITY ID#: CO-OWNER ID#: ACCOUNT ID#: I COMPLETE THE FOLLOIMNG BUSINESS FACILITY INFORMATION.- Is NFORMATION: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 ❑ BUSINES ACILITY NAME(This will be the BUSfNE Eon the HEALTH VERMI FACILITY ADDRESS(If FAGLfTY Is a MositEF000 UNrror FOOD VEHICLE use a C-�MmS6Ry Anrgt-= BUSINESS PHONE t �a lWfllb oAA�� N Suite fl CITY(If FAcrurYis a MOSILL,Foos UMTor use the("01MA saex Cine) ST ZIP BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 ! MAILING ADDRESS for Health Permit(if DIFFERENT from Facility Address) Attention or Care Of MAILING ADDRESS CITY STATE ZIP SIC CODE: APN ft: COMMENT: ACCO(LUTADWRESrfees and charges: OWNER ❑ FACILiiY1BUSINESS ❑ Rn LiNC AHD C omprjANrF. ArKNowLEDCMFNT: L the undersigned Applicant, certify that I am the Owner, Operator, or Authorized Agent of this Business, and I acknowledge that all PERNV FEES,PENALTIES,ENFORCEMENT CHARGES and/or HouRLY CHARGES associated with this operation will be billed to me at the address identified above as the ACCortNTAnnREss for this site. I also certify that all information provided on this application is true and I correct; and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNW Ordinance Codes and/or Standards and STATE and/or FEDERAL Laws and ReLyulations. APPLICANT NAME: Please PSIGNATURE: rint i TITLE: DATE DRIVER'S LICENSE# 1 # Approved By Date Accounting Office Processing Completed By DateZiff k!jL I 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 t OCATION except } UST Program(Use SWRCB forms) EHD 48-02-035 Masterfite Record-Green 101912003