Laserfiche WebLink
F o D SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> MAY 2016 <br /> SH'C ffUWgEi1T7'`fl PK Y OWNER ID# CASE# r <br /> PERMIT/SERVICES <br /> OWNER FELE <br /> COIj'PLETE'THEFOLLOW11VGBUSINESS OWNER hvFORl9,4TfOfil' OHECKIF OWNER CURR.-Air[rONFXE w/rHEHD❑ <br /> BUSINESS `� L. V © � PHONE: <br /> OWNER'S(NAME (� -G <br /> First MI Last <br /> f BUSINESS DAME(if di(ferentfromOwner Name) oc Sec rTax ID:# <br /> s � - r _Y <br /> } <br /> OWNER'S HOME ADDRESS 5 60C)QGLIEVS V 19Q t V <br /> CITY t " STT zip S <br /> OWNER'S MAILING ADDRESS (If different from Owner's Address) Attention orCare of 7 aC <br /> MA1LIHG ADDRESS CITY =STATE ZIP <br /> TYPE OF OWNERSHIP: ' <br /> i <br />�1 CORPORATION❑ INDIVIDUAL M PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY OTHER❑ <br /> FACILITY FILE <br /> } <br /> c FACILITY ID#; CO-OWNER ID#: ACCOUNT ID I#: <br /> CORSPLETETHEFOLLCWINGBUSINESS FACILITY INFORMAfl0ty. <br /> [5 th15 a NEW Business LOCATION or Vr=HICLE toot previously regulated by the ENVIRONMENTAL HEALTH YES ISO ❑ <br /> Is this an ExiSTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No E <br /> I <br />{ BUSINESS#FACILITY NAME(This will be the HuSINEssMAMEOn the HEALTH PERMIT) <br /> li 5 0 K) <br /> FACILITY ADDRESS(If FActurris a Mros;LEF000 UN?or FOOD VEHICLEOSe the COMMI55aaX ADDRESS) FBIISINESS PHONE r <br /> `,q J G G 0Ci u G L.A SFIR'.'Strpetftmber Direction 0 0 l u t� Suite# G -6 0`E s <br /> CITY(if FAGurris a MosrLE FOOD UNrror FOOD VEHICLE use the COMMISSARY CITY) STATE-CA <l <br /> BOARD OF SUPERVISOR DISTRICT TLocA­noN CODE KEY1 KEY2 <br /> MAILING ADDRESS for Health Permit(If DIFFERENrfrom Fac'fityAddress) Attention orCare Of <br /> MAILING ADDRESS CITYSTATE Zip <br /> SIC CODE: APN M COMMENT: - <br /> ACCOUNTADDRESS for fees and charges: OWNER FACILITYIBUSINESS' ❑ <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner, Operator,or Authorized Agent of this Business,and <br />! i acknowledge that all PERMIT FEES,PENALVE5,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation will be billed to me at the <br /> address identified above as the ACCOUNTADDRESS 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: �l3 C S A SIGNATURE. <br /> Please Print <br /> TITLE: DATE PHOTOCOPY REQUIRED <br /> 3 <br /> F <br /> 3 Approved ay Date �� It f i Accounting Office Processing Completed By Date <br /> A PROGRAM(EHD-48-02-034 Pinky or WATER SYSTEM(EHD 46-02-0.03)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 /> 8119108 <br /> fi <br /> r _ — <br />