Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> SHASEDSECTIONSFOREHD USE ONLY OWNER ID# <br /> OWNER FILE <br /> COMPLETE THEFOLLOW/NG BUSINESS OWNER INFORMATION-- CNEctr 1F OWNER CuRRENTL r oN Fue wiTH EH D❑ <br /> BUSINESS PHONE: <br /> OWNER'S NAME <br /> First Ml Last <br /> BUSINESS NAME(If different from Owner Name)1 � SOC Sea or Tax ID# <br /> RIv I i- �P1r <br /> OWNER'S HOME ADD ESS Qp I <br /> CITY �^ / ST E ZIP "�52o <br /> OWNER'S MAILING ADDRESS (If different from Owner's Address) Attention orCare of <br /> MAILING ADDRESS CITY STATE ZIP <br /> TYPE OF OWNERSHIP: <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTYAGENqXj STATE AGENCY❑ FED AGENCY OTHER❑ <br /> FACILITY FILE <br /> FACIurYID#: CO-OWNER ID#: ACCOUNTID#: AjP,06)4Jrf <br /> COMPLETE THEFOLLOW/NG BUSINESS FACILITY/NFORMAT/ON: <br /> [Isth�isam <br /> S thia NEW BuSIn¢SS LGDgrIDN Or VEHICLE not previously regulated by Che ENVIRONMENTAL HEALTH YE NO ❑ <br /> N_.W ExISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ NO ❑ <br /> BUSINESBIFACILITY NAME(This will be the BUSINESS NAMEon the HEALTH PERMIT) <br /> a 6 v <br /> FAclUTYADDRESS(If Fac /Tyles MoelLEFoaa UNlT rFOOD VEHI LE uae the COMMISSARY ADDRESS) BUSINESS PHONE <br /> 333 C' tr-- P(4e-q <br /> Suite# <br /> CITY(If FACIurYls a MoeaEFooD UN/Tor FOOD VEHicLE use the COMMISSARY Cm) STATE ZIP <br /> e CA r7 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> MAILINGADDRESS for Health Permit(If olFFERENTfrom Facility Address) Attend or Care Of <br /> PC> O , C)— C <br /> MAILINGADDRES TY STATE ZIP <br /> ef <br /> J^ZO <br /> SIC CODE: APN#: COMMENT: <br /> ACCOUNTADDRESS for fees and charges: OWNER ❑ FACILITYIBUSINESS ❑ <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that 1 am the Owner, Operator,or Authorized Agent of this Business,and <br /> I acknowledge that all PERMIT FEES,PENALTIES, ENFORCEMENT CHARGES and/or HOURLY CHARGES associated With this Operation will be billed tome at the <br /> 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 <br /> all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or <br /> FEDERAL Laws and Regulations. <br /> APPLICANT'S NAME: s SIGNATURE: <br /> Pleas Pdnt <br /> TITLE: DATE DRIVER'S LICENSE# <br /> PHOTOCOPY REQUIRED <br /> Appravad Sy Data Accounting Office Processing Completed By , Q Data <br /> 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 LOCATION <br /> except UST Program(Use SWRCB forms) <br /> EHD 48-02-035 Masterfile Record-Green <br /> 8/19/08 <br />