Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> SHADED SECTIONS FOR EHD USE ONLY OWNER ID# OK1002- ,30 CASE# <br /> OWNER FILE <br /> COMPLETETHEFOLLOw/NG BUSINESS OWNER/NFORMAT/ON: CHECKIF OWNER CURRENTLYONFILEw1THEHD❑ <br /> BUSINESS <br /> C L /OWNER'S N�MEPHONE: <br /> OWNER'S NAME U First MI Last zUy ?�y- sG)Z7 <br /> BUSINESS NAME(If different from Owner Name) Soc Sec orTax ID# <br /> OWNER'S HOME ADDRESS: <br /> CITY .� STATE ZIP GS I <br /> LNy 'SMAILINGADDRESS (If different from Owner's Address) Attention orCare of <br /> ADDRESS CITY / / G1� STATE L� ZIP G <br /> TYPE OF OWNERSHIP: <br /> CORPORATION❑ INDIVIDUA PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID##: 6e) ! CO-OWNER ID#: ACCOUNT ID#: <br /> COMPLETE THEFOLLOwINGBUSINESS 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 ExISTING Business LOCATION but a NEW TYPE of regulated Business? YEs ❑ No ❑ <br /> BUSINESS/FACILITY NAME(This will be the BustNEss NAMEon the HEALTH PERMIT) APN: <br /> FACILITY ADDRESS(If FAC/L/TYis a MOBILEFOOD UNiror GO VEHICLEUS8 the COMMISSARY ADDRESS) BUSINESS PHONE: <br /> Street Number Direction Street Name Street T e Suite# <br /> CITY(if FACILITYIs a MOBILE FOOD UNIT or FOOD VEHICLE use the COMMISSARY CITY) STATE Zip <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE FKEY1 KEY2 <br /> MAILING ADDRESS f0rHeE 1th Pe1M&(If DIFFERENTfrom Facility Address) Attention or Care Of / G <br /> MAILING ADDRESS CITY 3STATE <br /> EMAIL ADDRESS FOR INVOICE INVOICE <br /> INVOICES EMAIL 1 EMAIL 2 <br /> EMAIL ADDRESS FOR PERMIT PERMIT <br /> OPERATING PERMITS EMAIL'I EMAIL2 <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 /> 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 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: wozp U SIGNATURE: <br /> Please Print <br /> TITLE: DATE / DRIVER'S LICENSE# <br /> PHOTOCOPY REQUIRED <br /> Approved By Date Accounting Office Processing Completed By Data <br /> A PROGRAM(EHD 48-02-034 Pink)or WATER SYSTEM(EHD 48-02-003)form must be completed for each EHD regulated operation at this LOCATION <br /> except UST Program(Use SWRCB forms) <br /> EHD 48-02-035 Masterfile Record-Green <br /> 9/14/2020 <br />