Laserfiche WebLink
SAN JOAQUIN COUNTY.PUBLIC HEALTH SERVICES • ENVIRON TAIL HEALTH DIVISION <br /> FORM (EH0015(REwSE010/02/88) <br /> fj <br /> DATE 2 qx MASTERFILE RECORD INFORMATION <br /> SHADED SEC77ONS FOR EHD USE OM Y 'OWNER IDf �pJ.(, ,. , .�� Case# <br /> OWNER FILE <br /> COMPLETE THEFOLLOwtNGBUSINESS OWNER INFORMATION. CHEcxiF OWNER CURRENnroNFILE wnnEHO <br /> .................................................................................................................................................................................................................. ........................................................................... <br /> BUSINESS OWNER PNONE <br /> NAME ------------------------------------------ <br /> i................................ <br /> ..................................5W.......................................M(..............................................A9flf................................... <br /> ...1 I <br /> BugwESS (if 7frommer Na91n SOC SEc/TAz IDf <br /> 77i <br /> OWNERHoaEADDRESS DRIVER'S LICENSEE <br /> City STATE ZIP <br /> MUUNOAooRESS ND/FFERENTfrom Owner Address Attention:or Care of(apMwao <br /> l <br /> ,, Ur <br /> � I.Iirsm. STD) <br /> Mailing Address City State Zip <br /> TYPEOFOWNERSHIP- <br /> CORPORATION INDIVIDUAL El PARTNERSHIP 13 LOCAL AGENCY L1 COUNTY AGENCY C] STATE AGENCY El FED AGENCY OTHER 11 <br /> FACILITY FILE <br /> FACILITY ID III ' If� CROSS REF ID dI ..:; ' ACCOUNT ID f <br /> COMPLETETHEFOLLOw/NG BUSINESS FACILITY INFORMATION., <br /> Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DIVISION? YES ❑ No ❑ <br /> Is this an E)0SnNG Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ❑ <br /> Bula ACILnYNA1E T s wlu BFW NAME ON HEALTH PERMIT) <br /> C ��� � r <br /> FACIDTY ADDRESS(IF FACILI>t'ISA MOmI FOOD UNI TOR F000✓EN/ USE CO MMISsARY ADDRESS1 SIIREf BUSINESS PHONE <br /> CRY IFFAauL ISA MOBILEFOOO Uuriw FOOD✓EHICLEUSECOMMISSARY ADDRESS CIW STATE I ZIP <br /> 'BOARDOF SUPERVISbRDSTRICT- LOCATIONCOOE KEY1 KEY2. <br /> Mailing Address forHaa/fh Parmif ifD/FFERENTfrnm Facf//fyAddresv ! Attention:or Gra Of(opNona/) <br /> Mailing Address City '. STATE ' ZIP <br /> SIC CODE APNf COMMENT:. <br /> THIRD PARTY BILLING INFORMATION: Complete if Billing Party is different from Business Owner Identified above. <br /> ....... ...................................................................................................................................................................................................................... ........................ ................. <br /> BUSINESS NAME Attention:orGre Of (options// <br /> Mailing Address -UZp 7 / <br /> �/��,/, �///�� ,,/�// y (itlJ-(i 'C (gam V b <br /> CITY �(/('U(.4C/S ` ` ` A 'l�P� � <br /> AccounrrADOREss for fees and charges OWNER ❑ FACiLITY/BUSINESS ❑ THIRD PARTY BILUN94 <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant, certify that I am the Owner, Operator, or Authorized <br /> Agent of this Business, and I acknowledge that all PERMIT FEES, PENALTIES, ENFORCEMENT CHARGES and/or HOURLY CHARGES <br /> associated with this operation will be billed to me at the address identified above as the ACCOUNTADDRESS for this site. I also certify <br /> that all information provided on this application is true and correct; and that all regulated activities will be performed in <br /> accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or FEDERAL Laws and <br /> Regulations. <br /> PLEASE PRINT <br /> APPLICANT NAME SIGNATURE <br /> TITLE DRIVER'S LICENSE f <br /> (PHOTOCOPY REQUIRED) <br /> Approved By Date Accounting:Offee Processing Completed ByZZ I Data �, �7 <br />