Laserfiche WebLink
SAN aJOAQUIN COUNTY ENVIRJNMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> SHADED SEC TIONS FOR EHD USE ONLY OWNER ID# d(�Dp /(pCASE# <br /> OWNER FILE <br /> COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION: CHECKIF OWNER CURRENTLYON FILE W/THEHD <br /> BUSINESS PHONE <br /> OWNER NAME --- M q [[_ "Z, // „ <br /> First MI Last C/ '7V� V `��{/ <br /> BUSINESS NAME(If different from Owner Name) Soc Sec orTax ID# <br /> Ort 1�4S�_ . <br /> OWNER HOME ADDRESS -2Z0 V). <br /> CITY /T <br /> OWNER MAILING ADDRESS(If different from Owner Address) Attention orCare of <br /> MAILING ADDRESS CITY STATE ZIP <br /> TYPE OF OWNERSHIP: <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ LOCALAGENCM COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID#: f Ave CO-OWNER ID#: ACCOUNT <br /> COMPLETETHEFOLLOW/NG 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 /> BUSINESS/FACILITY NAME(This will be the SuswEssNAt+Eon the HEALTH PERMIT) <br /> S-M c L+L Iv -t - <br /> FACILITY ADDRESS(if FACQ/T✓Is a MOB/LE FOOD UN/Tor Food VEHICLEuse the COMMISSARY ADDRESS) BUSINESS PHONE <br /> ,ccSuite# Czoy �yr�—Uz i <br /> CITY(if FAchuTYlsaMOEI EFOODUM7orFOODVErxcLEusetheCoMMIssARYCITY) STAIE ZIP <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE /" R ("'T KEY1 KEY2 <br /> MAILING ADDRESS for Health Permtt(If DIFFERENTfrom F/'XtyAdd• ss•. Attention orCare Of <br /> -0 C <br /> MAILING ADDRESS CITY 0 P C* <br /> /7 0 s,r-t c ( -(C4m, STATE 0/+ ZIP C1 C_:�, <br /> SIC CODE: APN#: I 2 0 5 00 7 COMMENT: V Y I <br /> dh^r^<7IIA/Tdnnf7F.S.S for fees and charges: OWNER ❑ FACILITY/BUSINESS ❑ <br /> HILLING AND COMPLIANCE ACKNOYN'I FDGMFNT: I, the undersigned Applicant, certify that I am the Mover, Operator, or Authorized Agent of this <br /> Business, and I acknowledge that all PERMIT FEES,PENALTIES,ENFORCEMENT CIIARGES and/or HOURLY CHARGES associated with this operation will be <br /> billed to me at the address identified above as the ACCOUNTADDRESS for this site. I also certify that all information provided on this application is true <br /> and correct; and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Re ulations. <br /> APPLICANT NAME: SIGNATURE: <br /> Please Print ' <br /> TITLE: I DATE DRIVER'S LICENSE# 2 <br /> Approved By t� i Date �/ I t f r Accounting Office Processing Completed By Date <br /> A PROGRAM {EHD 48-02-034 Pink) or WATER SYSTEM (EHD 46-02-003) form must be completed for rash EHD regulated operation at this L QCATION <br /> except UST Program(Use SWRCB forms) <br /> EHD 48-02-035 Masterfile Record-Green <br /> 10/9/2003 <br />