BILLING - Laserfiche WebLink

Home Browse Search

SAN JO UIN COUNTY ENVIRONMENTAL HEALTH PARTMENT 041ASTERFILEIRECORD INFORMATION Ft—m SHADED SECAONSFOR END USE ONLY OWNER ID# p 7S'` CASA# OWNER'FILE COMPLETE THE FOLLOWING BUSINESS OWNER 1NFORMAvom CHECKIF OWNER CURRFNTLYONFILEKITH EHD BUSINESSv � NA 19 PHONE OWNER NAME //) First Mr Last Q vOF BUSINESS NAME(If different from Owner Name) r Tax ID# I 5oceCo s e:;K. OWNER HOME ADDRESS (� CITY Q STATE ZIP OWNER MAILING ADDRESS (If different from Owner Address Atfentlon or Care of fed MAILING AaDRESS CITY STATE ,ZIP TYPE OF OWNERSHIP: CORPORATION❑ INOMDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ p FACILITY FILE FACILITY ID#: 0 0 �q ! CO-OWNER ID#: ACCOUNT ID#: COMPLETETHEFOLLOWING BUSINESS FACILITY INFORMATION: Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES No ❑ is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YEs itel No ❑ BUSINESSJFACILITY NE(This will be the BusrNr ss N on the HEALTH PERMIT) rti # FACILITY ADDRESS(If FA(cram Is a MoarLE Food UNtTOr FOOD VEHICLE use the COMMISSARY nnnRFccl I 143 �`/ C�'t'� � �d(�f �� gS��CJ BUSINESSP/H�O]NE Streetm r N ✓ T suite# Q t (J CITY(If FAoxrrvts a MoaLLE FooD UNIT or Fow VEHICLE use the rmmm uRY CO STATE zip BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 l(EY2 MAILING ADDRESS for Health PerMit(!f DIFFERENTfrom FacifityAddress) Attention or Care Of P a )6.0 222[ S S E_ ✓t r2_A,,,-c 0,,.J 7-4-cs MAILING ADDRESS CITY f I STATS ZIIq SIG CODE; AP (' N#: COMMENT: C� t— [ drrnfrNTADDRESSforfeesandcharges: OWNER IaI FACILITYIBUSINESS ❑ Bft.2.IHc AND CoMPt,mNrE ArKNowl.rnrm ENT: L the undersigned Applicant, certify that I am the Owner, Operator, or Authorized Agent of this Business, and I acknowledge that all PERMV,FEES,PENALTIES,ENFORCEMENT C/LARGES and/or HOURLY CHARGES associated with this operation will be billed to me at the address identified above as the AccoUNTADDRE.SS 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 haws and Re ulafions. APPLICANT NAM SIGNATURE: } Please Print J TITLE: DATE (f [)RIVER'S LICENSE# Il Approved ByC,-CAO 3-2 f Date 4 C(} Accounting Office Processing Completed By —v-- Date I o A PROGRAM(EHD 48-02-034 Pink)or WATER SYSTEM(EHD 46-02-003)forth mlJst be completed for each EHD regulated operation at this 10GATION except UST Program(Use SWRCB forms) EHD 48-02-035 Masterfile Record-Green 10/9/2003