Laserfiche WebLink
SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES -ENVIRONMENTAL HEALTH DIVISION <br /> MASTERFILE RODRD INFORMATION FOR -H 00 1 5(Revised 6194)} <br /> New Facility Under Construction IL Data <br /> SHADED SECT/ONS FOR LOCAL USE ONLY OWNER FILE INFORMATION ti D-�' !o .5 <br /> CHECK BOX:IF OWNER ON FILE <br /> Please complete the following facility OWNER information: <br /> Owner Name Home Phone <br /> Owner DBA(if DIFFERE T from Owner Name) Business Phone <br /> Owner Address <br /> - <br /> City Stats <br /> Meiling Address <br /> if DIFFERENT from Owner Address <br /> Care Of or Attention <br /> (optional) <br /> Mailing Address City State Zip <br /> $uameasCode Type of Owner Business <br /> FACILITY FILE INFORMATION <br /> FACILITY:ID # <br /> Please complete the following FACILITY information- <br /> Facility/Business Name(This will be Name on Health Permit) <br /> La•, F- 1 ,0r(C W'oy,4,5 <br /> Facility Address (If Facility is a Mobile Food Unit or Vehicle-See below! Business Phone <br /> X 3 0 Woo) CLA'Avc 51V-f�Ql (:Ioq ) 3bq - 9�3� <br /> City State Zip <br /> 9h3-"1 � <br /> CENSUS TRACT':: BD OPSUPERVISOA DISTRICT LOCATION CODE <br /> Mailing Address(for Health Permit) <br /> if DIFFERENT from Facility Address <br /> Care Of or Attention { <br /> (optional/ I l a✓A I� <br /> Mailing Address City State Zip <br /> SIC:Code Ust Eecillty Status Code . General type of Business at this Bueinasa Coda <br /> Location <br /> Bti§loess Type <br /> Please complete the following information if Commissary or Operation Location (such as fair or festival) is different from <br /> Facility Address: <br /> Business Name <br /> Address of Operation Phone <br /> City State Zip <br /> CGNSUQ TRACT BO OF.SVPERVIS0 DISTRICT LOCATIpN:ODE <br /> [Send all Invoices for Permit and Service FEES to: (Circle one OWNER FACILITY/BUSINESS <br /> A PROGRAM EH 00 59 or WATER SYSTEM EH 00 59w form must be completed for each Environmental Health regulated <br /> operation at this LOCATION except UST Program (Use SWRCB forms) <br /> s ve etr <br /> , b : n.. ... <br /> : 'ewew ; _ <br />