Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />SHADED SEcnoxs FOR EHD UsE ONLY ow Top OWe,;o243/0 CASE III <br />OVYNER FILE <br />F!nuD cTc TNR Fnl I nwimaRI IAIMCRR nWNFR/NFORMA T/nN• CHECK /F OWNER CURRENTL Y ON Fit 10THEHD <br />BUSINESSPHONE: <br />OWNER'S NAMET <br />Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES <br />NO ❑ <br />e <br />BUSINESS NAME (II <br />tRamOwner Name) <br />APN:SEt <br />SGC Seo or -Tax ID p <br />OWNER'S HOME ADDRESS: <br />BUSINESS PHONE: <br />s"ej I E 1 <br />CRY <br />STATE <br />ZIP <br />STA n <br />AIL, ING ADDRESS (If diAnrord/rwn� eo Address) <br />V IV rM(U( I-II. )T/\ <br />[W2� <br />Attention oFCare` f <br />1U,DRESS <br />BOARD OF SI WERVISOR OmTpj6 <br />CITY <br />KEY1 <br />STATE })�I <br />ZAP <br />R&5? I`% <br />FACILITY FILE <br />FACILFTYID#: � j�j'j g I Co-OwNERID#: I ACGDUN 1D#. IIX�S( y�T I <br />nnuDN cTc Tuc cnI I nwiNn Rl IRINF444 FACII ITV /NFnRMAT/nAr <br />Is this a NEW Business LOCATION or VEHICLE net previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT! YES ffl NO ❑ <br />Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES <br />NO ❑ <br />H <br />INESSIFACILITY (Tiswlabe MOR NRJERMIT) <br />APN:SEt <br />FACILITY ADDRESS(NFA=flYle a MCDILEF UMT FOOD VFHXt Use the COMMnSANYAODaESSI <br />lgtescad�rlo ZiuQ <br />BUSINESS PHONE: <br />s"ej I E 1 <br />M <br />C MY (if FAaurY m a MOmtE FORD UMror FOOD VEHIaf use the CoaurssN CITY l <br />STA n <br />ZIP <br />L� <br />BOARD OF SI WERVISOR OmTpj6 <br />LOCATION CODE <br />KEY1 <br />KEY2 <br />MAILING A00RESS forHBalu, Pefmit (If DIFFERENrho m F.,,CA//tyAddress) Z.�/` <br />Attention orCam Of L; Cev� Tnc <br />MAILING ADDRESS CITY �I LIUV O�CCd <br />(� I(a�j,0 <br />STATE K)C <br />ZIP !14- <br />GT U <br />EMAIL ADDRESS FOR <br />INVOICES <br />INVOICE /� <br />EMAIL 1 � 1' <br />p q �y ^l r� �yL\/.In C <br />h o )2—,0)1 I� —� 1. V I' I E�.7L�'�1 <br />INVOICE <br />EMAIL 2 <br />11 <br />EMAILADDRESSFOR <br />OPEMTNG PERMITS <br />PERMR \ \ �e I-"/' <br />EMAILI 1 <br />PERMR <br />EMAIL2 <br />1 I <br />AC�Q(/-A"VORESSfar fees and charges: <br />OWNER <br />FACILITY/BUSINESS ❑ <br />BILLING AND COMPLIANCE ACKNOWLEDGMENT: I, the undersigned Appliwnt, Certify that I am the Owner, Operator, or Authorized Agent of this Business, and <br />I acknowledge that all PERMR FEES, PENALTIES, ENFORCEdEJr CHa GEs andfor HOURLY CHARGES assoclated with this operation will be billed to me at the <br />address Identified above as the Accouvr ADDRESS for this site. 1 also Certify that all Information provided on this application Is true and correct; and that <br />all regulated activities will be pertormed In accordance with all applicable SAN JOAOUIN COUNTY Ordinance Codes and/or Standards and STATE and/or <br />FEDERAL Lam and Reaulations. <br />30 kro�zkfck"- <br />TITLE: �A c Gfi v' -J-0 t I DATE <br />APPnrn I ey I ob.-, I A.Q=fta O,f P eeenitg CM49.13d sY i//SCS 1. on" S//b/zl 1 <br />A PROGRAM (EHD 48-02-034 Pink) or WATER SYSTEM (EHD 43-02-003) form must be Completed for Each EHD regulated operation at this LOCATION <br />except UST Program (Use SWRCB forms) <br />EHD 4e-02-035 Mastefile Reoord -Green <br />911412020 GsU It <br />7J�DleS- cgt4r �� <br />