Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> SHADED SECTIONS FOR EHD USE ONLY OWNER ID# <br /> OWNER FILE <br /> COMPLETE THE FOLLOWINGSUSINESS OWNER INFORMATION: CHECKiF OW N E R CURRENTLY ON FRE wrnq EHD❑ <br /> BUSINESSL i-,--s <br /> �„� PHONE: <br /> OWNER'S NAME IL Fb MI Last �j(17 <br /> BUSINESS NAME(If d/Yfaentfmm Owner Nae) SOC C OfTax ID# <br /> oNs+ r- UG470d R04ediye. gees <br /> OWNER'$HOME ADDRESS <br /> CITY STATE ZIP <br /> OWNER'S MAILING ADDRESS(If di/rerentfromoenler's Address) Attention orCamof <br /> `filo )wfd LOIS rA <br /> MAILING ADDRESS CITY TATE ZIP <br /> r'� 2 <br /> TYPE OF OWNERSHIP: <br /> CORPORATION, INDMDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITYID#: (;Q�� U� CO-OWNERID#: <br /> COMPLETE THEFOLL007NG 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 ExIMNG Business LOCATION but a NEw TYPE of regulated Business? YES 1ANO ❑ <br /> BUSINESS/FACILITY N/#ME(This will be the �Ihe HEALTH PERMIT) <br /> FACILITY ADDRESS(If FACZmi a AksluE&W Uh Tor F000 Ve use the gv Aooaasl / BUSINESS PHONE <br /> N / /v<a6-�/i SAC/Avs e.<1f6 ST <br /> suite# <br /> CITY(if FAdurYls a MOeILEFOOD UWor FooD VEHICLEUS0 the Comissmy CITY I $�qTE Zip <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEYI KEY2 <br /> MAILING ADDRESS for Health Permit(if D RTROVrfrom Fad/itygodress) Attention arCam Of <br /> MAILING ADDRESS CITY STATE ZIP <br /> SIC CODE: APN#: COMMINr: <br /> ACCO[/NTAD lf&ffor fees and charges: OWNER FACILITY/BUSINESS ❑ <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: L the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and <br /> I 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 ACCOUNT ADDRESS 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: SIGNATURE: <br /> Please Pnnf <br /> E' DATE DRIVER'S LICENSE# <br /> PHOTOCOPY REQUIRED) <br /> Approved ey Date Accounting Office Processing Completed BY Date 3 �q <br /> A PROGRAM {EHD 48-02-034 Pink} or WATER SYSTEM {EHD 46-02-0031 form must be completed for each EHD regulated operaf(tion at this <br /> LOCATION except UST Program(Use SWRCS forms) <br /> EHD 48-02-035 <br /> 8/19/08 Masterfile Record-Green <br />