BILLING - Laserfiche WebLink

Home Browse Search

RECEOVEDAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT =x MAR Q $ 701MASTERFILE RECORD INFORMATION FORM $Ht%*RQ WI��IiWlC TH OWNER ID# ©I t J�D � CASE# vv ES OWNER FILE COMPLETE TMEFOLLOW/NGBUSINESS OWNER INFORMATION: CHECXlF OWNER CTtroNfrtEwrrvEHD❑ FFBUSFNESs ESS TPHONE., R'5 NAME -� 'e I C S (2�)(, 7•F//(0 First MI Last I NAME(If,different from Owner Name) • or Tax ID# A,J, F-ER iC� cN7r-,2Pk t,�z a- 99 (�73 OWNER'S HOME ADDRESS CITY STATE ZIPI OWNER'S MAILING ADDRESS (If different from Owner's Address) Attention orCare of 4 a. ax Ho MAILING ADDRESS CITY STATE ZIP 11 r� A 96 7 TYPE OF OWNERSHIP: II CORPORATION❑ INDIVIDUAL PARTNERSHIP ElLOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY OTHER❑ FACILITY FILE FACILITY ID#:jCA00230& CO-OWNER ID#: ACCOUNT ID#:,.f 9ZZ COMPLETETHEFOLLOWINGBUSINESS FACILITY INFORMATION: I Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL H LTH YES NO ❑ Is this an EXISTING Business LOCATION but a NEw TYPE of regulated Business? YES No ❑ BUSINEsSIFACILITYNAM9(This will be the Bustxess NAmEon the HEALTH PERMIT) FAciLrry ADDRESS(If FACILITYis a Mosa.EFooD UNiTor FooD VExicLEuse the COMMISSARY ADDRESS! BUS I ESS PHONE 2193 2 3 s. ' P,�4 12�,q a=t Mimber Direction Stregt Name Street Type Suite# t. CITY(If FACILITY IS a MoBILEFODD UNIT Or FOOD VEHICLE use the COMMISSARY CITY) STATE Zip iL GA- gFF5e3?S9 BOARD OF SUPERVISOR DISTRICT ' LOCATION CODE KEY1 KEY2 4 MAILING ADDRESS for Health Permit(If DIFFEREw-from FacilityAddress) Attention orCare of P a• 86 4&lo F&,,�P-1cW MAILING ADDRESS CITY ,i rt rTC TATEZIP SIC CODE: APN# COMMENT: _I} F COUNTADDRESS for fees and Charges: OWNER FACILiTYIBUSINESS ❑{I 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 will be billed to me at the address identified above as the ACCOUNTADDRFss 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 Staridards and STATE and/or FEDERAL Laws and Regulations. IG APPLICANT'S NAME: .4-,vgy ' kefuc-iS SIGNATURE: -�✓/; Please Print TITLE: �v�rv�� Q1° P � DATEIS//� DRIVER'SLICENSE# PHOTOCOPY REQUIRED l Approved By Date Accounting tlfflce ProcessEng Completed By Date „ lip A PROGRAM{EHD 48-02-034 Pink)or WATER SYSTEM{EHD 48-02-003}form must be completed for each EHD regulated oper tion at this LOCATION except UST Program(Use SWRCB forms) 11 EHD 48-02-035 Masterfile Record-Green 8119/08