BILLING - Laserfiche WebLink

Home Browse Search

SAN JOAO''IN COUNTY ENVIRONMENTAL HEALTH DF- RTMENT , , W_ . W, , _STERFILE RECORD INFORMATION FOR. I SHADED SECTIONS FOR EHD USE ONLY OWNER ID # I P� / �Q " I CASE # OWNER FILE i+.,...,, •na DI lcu.iccc r11AIKIPP 1Air,1vAAATIrIN• I-)gFCKIF OWNER CURRFNTL YON F/LE WITH FHD vvrnr �� r c - �- c' a /j —A PHONE BUSINESS (yam MI Last OWNERNAME i BUSINESS NAME (if different fnwa_OwnerName) # FACILITY ADDRESS (KFS aCnm is a MoeueFOOD UNLror FOOD 141 use the COMMISSARY nnBESS) OWNER HOME ADDRESS CITY/ C. , STATE ZIP G r OWNER MAILING ADDRESS (if different from Owner Address) Attention orCare of STATE ZIP MAILING ADDRESS CITY ti" STATE ZIP (15 r� TYPE OF OWNERSHIP: CORPORATION 9. INDIVIDUAL ❑ PARTNERSHIP ❑ LOCAL AGENCY ❑ COUNTY AGENCY ❑ STATE AGENCY ❑_ _ FED AGENCY ❑ OTHER U FACILITY FILE FACILITY ID #: C0-0WNER ID #: I ACCOUNT ID M .� n11Olu Coo r-AlI11 ITV /ut-!1-1.--Ar• 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 ❑ No BUSINESS/FACILITY NAME (This will be the BusrNEssNAmEon the HEALTH PERMIT) FACILITY ADDRESS (KFS aCnm is a MoeueFOOD UNLror FOOD 141 use the COMMISSARY nnBESS) BUSINESS PHONE CITY (If FAaU7Yal a MOOLEFOOD Urrror FOOD VEP/CLE use the coMAassmy cm) STATE ZIP t�,n BOARD OF SUPERVISOR DISTRICT LOCATION CODE I KEY1 KEY2 MAILING ADDRESS for Health Perm/ DXFERENTfrom Facility Address) /n Attention orCare Of I el MAILING ADDRESS CITY /, / _ STATE Zr Li v SIC CODE: t` APN #: , 6 O 9 1 COMMENT: 4=0iWTAVDRF.S5for fees and charges: OWNER ❑ FACILITY/BUSINESS RII 1 IN( AND COMP] fANcE ACKNOWI.F.DGMFNT: I, the undersigned Applicant, certify that I am the Owner, Operator, or Authorized Agent of this Business, and I acknowledge that all PERWT FEES, PENAL77ES, ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation will be billed to me at the address identified above as the AccouNTADDRFce 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 applicAbJe SAN JoAQ/U oUNTY Ordinance \Coq s( APPLICANT AME: " ��- `_ SIGNATURE _� Please Print � { TITLE: C";1 ---,? /' DATE 1� &>� Z DRI 1113�^ER'SLoCtplJSniocnl � Approved By LAO Date i �' a �I Accounting Office Processing Completed By I Date C�Q — r. A PROGRAM (EHD 48-02-034 Pink) or WATER SYSTEM (EHD 46-02-003) form most be completed for each EHD regulated operation at this I nCATION except UST Program (Use SWRCB forms) n 1 EHD 48-02-035 w (f Masterfile Record -Green 10/9/2003