CONFIDENTIAL_RE 2019 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM Snw,to SCCFgh5 FOR EHO USE ONLY OWNER 100 1 0WINJI27OI4"% CASEp OWNER FILE ,�/ COMPLETE THEFOLLOWING BUSINESS OWNER INFORMAAOM CHECK IF OWNER CVRRENTL YONFiLE W" EHDCQ ---k BUSINESS11-4 OWNER'S NAME BUSINESSINAMETal"I=7onBre HEALTHPERMIT�7f 0r F`ILITY% ADDRESS IN Fn la a Afai xb UwrwA VeNxiruw tM CoMa:ssnnv Apoa[ss) BUSINESS PHONE D4 n Sle - Fuse ST ZIP 9 _ BOARD OF SUPERVISOR DISTRICT BUSINESSNAmE /dtrre-renffbn.n OwnsrNams) KEYt OWNER'SHOM 2 MAILING ADDRESS for HeaHlT Permit)if DIFFEREN Tfrom Facility Addivss) Atlantlen wCara Of CITY / STATE ZIP zip Z - OWNER'S MAIUNb ADDRESS (If ditliief fronrOwna!• Addnaa) corlva: Attantion iwCara of MAILING ADDRESS CITY STATE ZIP - TYFEOFOMEa 'P. FACILITY FILE FACILITY ID a: � 'IPJ CO.OWNER ID 7): I AccouNT ID if; COMPLETE THEFOLLOWING BUSINESS FACILITY INFORMATION: — ---_ IS this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO Is this an EKISTING Business LOCATION but NEW TYPE of regulated Business? YES ❑ NO ❑ BUSINESSINAMETal"I=7onBre HEALTHPERMIT�7f 0r F`ILITY% ADDRESS IN Fn la a Afai xb UwrwA VeNxiruw tM CoMa:ssnnv Apoa[ss) BUSINESS PHONE D4 n Sle - CITY (if ba MoenE FOoe UNT or Foci VEwciPusa tM COMMssvcv Cm1 ST ZIP 9 _ BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEYt KEY2 MAILING ADDRESS for HeaHlT Permit)if DIFFEREN Tfrom Facility Addivss) Atlantlen wCara Of MAILING ADDRESS CITY STATE ZIP SIC COOS: APNs: corlva: e,�C�DUNTADORESSfor fees and charges: OWNER ❑ FAOLfTY/BUSINES BILLING AND COMPLIANCE ACKNOWLEDGMENT: I, the undersigned Applicant, certify that I am the Owner, Operator, or Authorized Agent of this Business, and I acknowledgo that all PERMIT FEES. PENALTIES, ENFORCEMENT CHARGES and/or HOURLY CNARGES associated with this operation will be billed to me at the address identified above as the ACCDUNTADOREss 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 at applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or FEDERAL APPLICANT'S NAME: SIGNATURE: ,F'��C �i. 1� P/aare Pmf DATE �/GC/1 l '�{ TITLE' / DRIVER'S LICENSES h l � IPMOTOn[)PY Rrn111RF01 Approved BY I Dots I Accounding 0l ee Prousaing Compbbd 8y / jlfl I nab 7/2/,A-7 I A PROGRAM (EHD 48-02-034 Pink) or WATER SYSTEM (EHD 4842-003) form must be completed for each EHO regulated operation at this LOCATION except UST Program (Use SW RCB forms) EHD 48-02-035 Masterfile Record -Green 1ti-'07