Laserfiche WebLink
ti r SAN JOAr"'N COUNTY ENVIRONMENTAL HEALTH r-OARTMENT <br /> YASTI_RFILE RECORD INFORMATION FO <br /> 114 <br /> SWCD Seccims FOR EHD USE ONLY OWNER ID# l L` C CASE# <br /> OWNER FILE <br /> COMPLETE THE FOLLOMNG BUSINESS OWNER INFORMATION: CHECKIF OWNER CURRENTLY ONFUEWITHEHp <br /> BUSINESS S PHONE <br /> OWNER NAME <br /> First A <br /> Last CJ (J fo(J <br /> BUSINESS NAME(if different from Owner Name) Soc Sec or T ID# <br /> OWNER HOME ADDRESS <br /> CITY <br /> b a.\Y"- I STT ZIP 7 <br /> OWNER MAILING ADDRESS (If different 4m Owner Address) Attention or Care of <br /> q <br /> L�nlaNGADDR S CITY $T TE ZIP <br /> TYPE OF OVVNERSHIP: <br /> CORPORATION❑ INDIVIDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID#: C b ),0 j)5 CO-OWNER ID#: ACCOUNT ID T <br /> �S <br /> COMPLETE THEFOLLOWlNG BUSINESS FACILITY INFORMATI'ON. ; <br /> Is this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES NO ❑ <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES 5r No - <br /> BLI.SINESS1FACIuTY NAME(Th' will be the=t_ <br /> ssm-ion the HEALTH PERMIT) <br /> FACILITY ADDRESS(If FActirry is a M rLE FOOD U rror FOOD VEHICLE use the COMMISSARY ADDRESSI BUSINESS PHONE ' <br /> 5160 C Iybna2 U) 5AA Jl v2 (Z_Vq <br /> m rpireLwn SfreetNarne Street TvDe Suite# <br /> i CInFAC14,119 <br /> a MoaILEFOOD UN1ror FOOD VEHICLE use the COMMISSARY r-IDtp STATE ZIP <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> LING ADDRESS for Health Permft(If DIFFERENT from FacifffyAddress) Atten2;Z <br /> re Of <br /> ING ADDRESS CITY STM <br /> ZIP <br /> SIC CODE: APN#: COMMENT: <br /> AGrOf1NTAr)f)RESS_forfees and charges: OWNER ❑ FACILiTY/BUSINESS L� <br /> BIT I,,LIYC_AND l ompi.IANc'E ACKNowI.EDrmENT: I, the undersigned Applicant, certify that I am the Owner, Operator, or Authorized Agent of this <br /> Business, and I acknowledge that all PERMa.FEES,PENALTms,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation will be <br /> billed to me at the address identified above as the AccouNTADDRr.cs for this site. I also certify that all information provided on this application is true and <br /> correct; and that all regulated activities will he performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards <br /> and STATE and/or FEDERAL haws and Re ulations. <br /> APPLICANT NAME: SIGNATURE: <br /> lease Prin <br /> TITLE; DATEDRIVER'S LICENSE# <br /> Approved ByD?�.� Date � CS( Accounting Office Processing Completed By Date 2 <br /> 22 <br /> A PROGRAM(EHD 48-02-034 Pink)or WATER SYSTEM(EHD 46-02-0031 form must be completed for each EHD regulated operation at this I OCATION except <br /> UST Program(Use SWRCB forms) <br /> EHD 48-02-035 Masterfile Record-Green <br /> 10/9/2003 <br />