BILLING - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ♦ ENVIRON 'TAL HEALTH DIVISION DATE MASTERFILE RECORD INFORMATION FORM {EH 00-IS(RevlsEo 10/02!96) SHADED SECrlmsFOREHDUSEOmY OwNER:ID:# CasE# MWER FILE COMPLETETHEFOLLOW/NG BUSINESS OWNER /NFORMAT/ON. CHECKIF OWNER CURRENrzrONFIIEWITHEHD ........................................................................... ................................................................................................................................................................................................................. BUSINESS OWNER. ,�r, .- . c _ PHONE 16 NAME `y� �Q--__--_—_--�_,_�=3U lL`YK.lL1��`�'== __— ...................................................................Fist.......................................MI .............................. .................Oast............................ BUSINESS NAM (If different from Owner Name) SOC SEC/TAx ID III L14-(L�SPu tzs� S s - -C-o OWNER HOME ADDRESS DRIVER'S LICENSE# SOC a 199 P) Qty STATE ZIP ':j41IS-.c O OWNER MAILING ADDRESS if DIFFERENT from OwnerAddress ? Attention:or Care of (optional) �l Mailing Address City y State/ Zip � TYPE OF OWNERSHIP: CORPORATION❑ INDIVIDUAL❑ PARTNERSHI'a----,LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ FACILITY FILE —77 " FACILITY ID# s '' CROSS REF ID# ACCOUNT'ID COMPLETE THEFOLLOWI G BUSINESS FACILITY INFORMATION., Is this a NEW Business LOCATION or VEHICLE not Previously regulated by the ENVIRONMENTAL HEALTH DIVISION? YES ❑ NO Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ NO BUSINESS/FACILITY NAME(THIS WILL BE THE NAME ON HEALTH PERMIT) Proms LA pu,� �s s FACILITYADDRESS(IFFACILITYISA Momi-EFOODUNITORFOOD VEHICLE USE COMMISSARY ADDRESS) SUITE# BUSINESS PFpIJE �0 2S s, mk&Ar- kkr, Irac y CITY IFFACIUrYISA MosiLEFOOo UN/TORFOOD VEHICLE USECOM�MISSAR�Y ADDRESS CITY) �: STATE ZIP BOARD OF SUPERVISOR DISTRICT - LocknoK CODE KEYi �'' :: KEY2 Mailing Address for Health Permit WDIFFERENT from Facility Address Attention:or Care Of(optional) Mailing Address City STATE ZIP $IC CODE : APN# COMMENr THIRD PARTY BILLING INFORMATION: Complete if Billing Party is different from Business Owner Identified above. ..........................................................................................................................................................................................,.............................................................................................................. . BUSINESS NAMEw () �'pp E Attention:or Care Of (optional) PAY ..nN Mailing Address ' PHONE 1�0 1�ox bO�q alntt IQQ7 1��91 % ^ o3c�t CITY STATE ZIP S O Cv�Tb Cw O1 to A QU�I�DORFS4 for fees and charges OWNER•IUO,,NIENTIIOAtidfy?ijU SS ❑ THIRD PARTY BILLING BILLING AND COMPLIANCE ACKNOWLEDGMENT: I, the undersigned Applicant, certify that I am the Owner, Operato , or Authorized Agent of this Business, and I acknowledge that all PERVIT FEES, PENALTIES, ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation will be billed to me at the address identified above as the ACCOUNT ADDRESS 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 Standards and STATE and/or FEDERAL Laws and Regulations. PLEASE PRINT APPLICANT NAMESI / \. K v� r .L�VIA IAAN�&"g ' TITLEJ DRIVER'S LICEN # -21�/• _� �IP S PHOTOCOPY IRED ��- Approved By Date Accounting Office Processing Complete!