Laserfiche WebLink
SAN JON COUNTY ENVIRONMENTAL HEALTH WARTMENT <br /> ASTERFILE RECORD INFORMATION FORM <br /> SHADED SECTIONS FOR EHD USE ONLY OW NER ID# CASE# <br /> OWNER FILE <br /> COMPLETE THE FOL LOWINGBUSINESS OWNER INFORMAnow CHECKZF OWNER CURRE1MY0NFrLE wITHEHD <br /> BUSINESS 5Lv't/ `— ' ! PHONE: <br /> OWNER'S NAME \ <br /> J I <br /> First MI Last �� J <br /> BUSINESS NAME(If dffferentfrom owner Name)�-�/ Soc Sec orTax ID# <br /> C 1 1 � �� Li 9-7 Z <br /> OWNER'S HOME ADDRESS <br /> CITY M a ` STT zip grq 3 7 <br /> OWNER'S MAILING ADDRESS (If differentfrom Owner's Address) Attention orCare of Cl <br /> 5-z; S . 0 n s S�oy- <br /> MAILING ADDRESS CITY j �(�� $T� ZIP E <br /> TYPE OF OWNERSHIP: <br /> CORPORATION INDMDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITY <br /> D#: f -til' Ai fi "' CO-OWNER ID#: ACCOUNT ID#: <br /> COMPLETE THE POLL OWING BUSINESS FACILITY INFORMATION; <br /> Is this a NEW Business LOCATION or VEHICLE not previously/regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO <br /> Is this an E)aSTING Business LoCATION but a NEW TYPE of regulated Business? YESNo ❑ <br /> BUSINESS/FACILITY NAME(This will be the SusmEssNkmEon the HEALTH PERMIT) <br /> FACILITY ADDRESS(If FAQLtTYis a MOBILE FooD UNrror FDDD VEHiaEuse the CommissARY ADDRESS) <br /> S s � � � (B�moUSIwNE)SS 3PHONE <br /> Street Number �etName <br /> Suite# 7 <br /> CITY(If FACILITY IS a MOBILE FOOD UNIT or FOOD VEHICLE USe the COMMISSARY CITY) STATE zip <br /> V-Otrr C A 6) a <br /> [BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> MAILING ADDRESS for Health Permit(If DIFFERENTfrom FacilityAddress) Attention orCare Of <br /> MAILING ADDRESS CITY STATE zip <br /> SIC CODE: APN#: COMMENT: <br /> ACCOUNTADDRESS for fees and charges: OWNER ❑ FACILITY/BUSINESS <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and <br /> acknowledge that all PERMIT FEES,PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated With this operation Will be billed to me at the <br /> address identified above as the ACCOUNTADDRESS for this site. I also certify that all information provided on this application is true and correct;and that <br /> all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or <br /> FEDERAL Laws and Regulations. <br /> APPLICANT'S NAME: S � T—A �S u T_ SIGNATURE' <br /> Please Print <br /> TITLE: L -IJ DATE '2� I �j P OTOCOPYCREQUIRED) <br /> Approved By Date Accounting Office Processing Completed By Date ss�� <br /> CIL <br /> A PROGRAM {EHD 48-02-034 Pink} or WATER SYSTEM {EHD 46-02-003} form must be completed fo each EHD regulate oper tion at this <br /> LOCATION except UST Program(Use SWRCB forms) <br /> EHD 48-02-035 <br /> 8/19/08 Masterfile Record-Green <br />