Laserfiche WebLink
SAN JOA" COUNTY ENVIRONMENTAL HEALTH DARTMENT <br /> 1.__.STERFILE RECORD INFORMATION FOI., <br /> SHADED SECTIONS FOR END USE ONLY OWNER ID#. aj �t CASE# <br /> OWNER FILE <br /> COMPLETE THE FOLLOWWGBUSINESS OWNER WFORMATION: CHECKIF OWNER CURRENTLY ON FILE MTNEND <br /> BUSINESS VIA- p 1 PHONE <br /> OWNER NAME <br /> Fust 36/1 <br /> Ml Last <br /> BUSINESS NAME(if different from Owner Name) Soc Sec or Tax ID# <br /> OWNER HOME ADDRESS 7 <br /> CITY hI STATE ZIP <br /> OWNER MAILING ADDRESS of diftererd from Owner Address) Attention or Care of <br /> J <br /> MAIUNG ADDRESS CITY Ti;;TETZP <br /> TYPE OF OWNERSHIP: <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY ElFED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID#: 00 f 9-f):;;?� CO-OWNER ID#: ACCOUNT ID <br /> COMPLETE THE FOLLOINING BUSINESS FAC ILITYINFORMATION.- <br /> Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ER NO ❑ <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? �ES ❑ No <br /> BUSINESSIFACILITY NAME(This will be ft BUsinlm NAuEon the HEALTH PERMIT) <br /> FACILITY ADDRESS(if FArnnyIs a JNosuE Uxrror VErnccEuse a CommsSARY AnDRESS! BUSINESS PHONE <br /> � c v� .=t_.-= Zo v�� 163 <br /> sLdte <br /> CITY(If FACnnY is a M F)ao UMT or Foos VEwCCE use the STATE ZIP S -2 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> MAILING ADORE for Health Permit(H DIFFERENTfro m FacrlrryAddress) Attention or care Of <br /> �MAILING'ADDRESS CITY �+ �C' [� r� STATE ZIP <br /> SIC CooE: D 0 t{ q 'APN#. <br /> 4ernuurAQQRFS-for fees and charges: OWNER FACILITY/BUSINESS ❑ <br /> Rn.T,mr.. ANn Compi.lANrF. AcKNovvt_ynr,m NT: 1, the undersigned Applicant, certify that I am the Owner, Operator, or Authorized agent of this <br /> Business,and I acknowledge that all PERM4,FEES,PENALTTES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation will be <br /> 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 <br /> correct; and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ord' ante Codes and/or Standards <br /> and STATE and/or FEDERAL haws and Reetilations. <br /> ` r <br /> // <br /> APPLICANT NAME: SIGNATUR : r <br /> Please Print <br /> TITLE: -�� DATEJ — DRIVERS LICENSE# <br /> Approved By- 5 Date V0 C01 Accounting Office Processing Completed By Date <br /> A PROGRAM{END 48-02-034 Pink}or WATER SYSTEM(END 46-02-003)form must be completed for each EHD regulated operation at this I fKATION except <br /> UST Program(Use SWRCB forms) <br /> EHD 48-02-035 Masterfile Record-Green <br /> 10/9/2003 <br />