Laserfiche WebLink
SAN JOAQUIN COUNT:' F '_IC HEALTH SERVICES r ENVIRON' T HEALTH DIVISION <br /> DATE MASTERFILE RECORD INFORMATION FORM (EHWIS(REYIsEO10102196) <br /> L449EOSEC77ONSFOR DUSECMLY OWNER ID 9 CA.E.# <br /> OWNER FILE <br /> .COMPLETETHEFOLLOW/NG BUSINESS OWNER INFORMATION: CHEOR�F OWNERCURRENnYONFILEWIMEHO <br /> ................................................................................................................................. <br /> BuslHEss OwHEa ' PRONE <br /> NAYS L_________________�_ i E <br /> _____________i i <br /> ...................................................................fi!st....................... <br /> _...._........MI..._....._.........._....... <br /> _._..�.SIN.t...___......._. I i <br /> ..._._.......... <br /> BuNwis;NAME(if di?aisnt floor,Owner Mame) i 9aC sEc/TAx 10# <br /> OWNER Now ADDRESS DRrvet's LIcause <br /> STATE i LP <br /> OWNERMAwHCADDREW ifU/FFERENTJh:nn O,rnerAddrosa Attention:or Care of(ophona/J <br /> Mailing Address City i stab Zip <br /> TYPE OF OWNERSHIP: <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ DTHER❑ <br /> FACILITY FILE <br /> FACILITY ID# 1 . CROSS REF.ID.# ACCOUNT ID'# <br /> COMPLETETHEFOLLOW/NG BUSINESS FACILITY INFORMATION: <br /> Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENvIRoNMENrAL HEALTH DIVIsioN? YES ❑ No <br /> Is this an OUSTING Business LOCATION but a NEW TYPE of regulated Business? YES ( No ❑ <br /> Busiwss/FACIuw NAME(Tws wILL BE THE NAME ON HEALTH PERMIT)i^� <br /> I n' ntz4,-co-j- r .o C-A— <br /> FA iuw ADOREw(/FFAciL ISAMOBREF\ UmrT Fo VOMC[E COIMBIARYAO rss1 sU1E# BuipwaspRow <br /> Cm/FFACIu"ISAMOO,L Faooumrm FOOOVEH/OtE CoMM89ARYAOOREm CRY1 i STA TF� ! Zw <br /> l I 't'u CGS <br /> BMRDOFSIWERV.SORDISTRICT LOCATONCODE KEPT KEY2 <br /> Mailing Addrass for Hoa/m Permit ifo/FFERE/Vrfrom Facility Addr Attention:or Care Of(optional) <br /> Mailing Address City ! STATE ZIP <br /> SIC CODE- APN# COMMEM: <br /> THIRD PARTY BILLING INFORMATION: Complete if Billing Part/ is different from Business Owner Identified above. <br /> ......... <br /> ........ ........................................................................................................................................................................................................................................................................................ <br /> BUSINESS NAME i Attention:or Care Of (op#enaQ <br /> Mailing Address PHONE <br /> Cm STATE ZIP <br /> A - o a/rAaOw cc for fees and charges OWNER ❑ FACIt1TY/BUSINESs THIRD PARTY BILLING ❑ <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I, the undersigned Applicant, certify that I am the Owner, Operator, or Authorized <br /> Agent of this Business, and I acknowledge that all PERNUT FEES, PENALTIES, ENFORCEMENT CHARGES and/or HOURLY CHARGES <br /> associated with this operation will be billed to me at the address identified above as the ACCOUNTADDRESS for this site. I also certify <br /> that all information provided on this application is true and correct; and that all regulated activities will be performed in <br /> accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or FEDERAL Laws and <br /> Regulations. <br /> PLEASE PRINT <br /> APPLICANT NAME SIGNATURE <br /> TITLE DRIVER'S LICENSE# <br /> (PHOTOCOPY REOUIRED) <br /> Approved By Oate Accounting ice Processing Completetl B Dab <br />