BILLING - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ,TERFILE RECORD INFORMATION FC SHADED SECTIONS FOR EHD USE ONLY I OWNER ID # I © ) O CASE # OWNER FILE COMPL ETE THE FOL L 0 WING B U S I N E S S OWNER INFORMATION: CHECKIF OWNER C//RRFNTiYnNFTI FwrTHFHIII—I BUSINESSPHONE' OWNERS NAME YES ❑ NO ❑ BUSINESS FACILITY NAME (This will be the BusmEssNAmEon the HEALTH PERMIT) -7 G� First MI - Last BUSINESS NAME (If different from Owner Name) SOC Sec or Tax ID # OWNER'S HOMEADDRES. �� U� 4"a CITY �r D� J STATE ZIP C v OWNERS MAILING ADDRESS (If different from Owner's Address) Attention or Care ofL MAILING ADDRESS CITY $TATE ZIP TYPE OF OWNERSHIP: CORPORATION ❑ INDIVIDUAL PARTNERSHIP ❑ LOCAL AGENCY ❑ COUNTY AGENCY ❑ STATE AGENCY ❑ FED AGENCY ❑ OTHER ❑ FACILITY FILE FACILITY ID #: CO-OWNER ID #: COMPLFTFTHF FOLLOWINC'BUSINFSS FACTI TTY TNFnpmdTTnty Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ❑ YES ❑ NO ❑ BUSINESS FACILITY NAME (This will be the BusmEssNAmEon the HEALTH PERMIT) FACILITY ADDRESS (If FA carrris a MoetLE FooD UNtro�� r fuse the COMMISSARY ADDRESS) o � / N` �(// Street Number Dire ion Street Name Street Type Suite # BUS ��S� PHONE �– f_j 6 CITY (If FAm ITYIS a r ,Fp OD UNIT FOOD VEHICLE IJSf the COMMISSARY CIN) STATE zip � BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 MAILING ADDRESS for Health Perm/t(If DIFFERENTfrom FacilityAddress) Attention or Care Of MAILING ADDRESS CITY STATE ZIP SIC CODE: APN #: COMMENT: ACCOUIVTADDRE55 for fees and charges: OWNER ❑ FACILITY/BUSINESS ❑ BILLING AND COMPLIANCE ACKNOWLEDGMENT: I, the undersigned Applicant, certify that I 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 WIII be billed t0 me at the address identified above as the ACCOUNT ADDRESS 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 =EDERAL Laws and Regulations APPLICANTS NAME: SIGNATURE: Please Pnnt TITLE: DATE DRIVER'S LICENSE # (PHOTOCOPY REQUIRED) Approved 8y 1 I Date' J' '<�J 11 l/ Accounting Office Processing Completed By /� I Date Approved A PROGRAM {EHD 48-02-034 Pink} Or WATER SYSTEM {EHD 46-02-003} form must be completed for each EHD regulated opera ion at this LOCATION except UST Program (Use SWRCB forms) EHD 48-02-035 Masterfile Record -Green 8/19/08