BILLING - Laserfiche WebLink

Home Browse Search

, SEP-1,6-2008(TUE) 13; 52 Proactiue Northern Container (FRH) 12099a8Ola2 P. 002/003 SAN JOAQIWOUNTY ENVIRONMENTAL HEALTH DIOTMENT MASTERFILE RECORD INFORMATION FORM SHADED SECRONS FOR EHD USE ONLY OWNER ID III Q CASE# OWNER FILE COMPLETE THE FOLLOWING BUSINESS OWNERINFORMATION: CHECKIF OWNER CURRENTLY ON RLE WITH EHD BUSINESS '-p PHONEp / OWNER NAME FAst MI Las �� 7 —S-114^O//� BUSINESS NAME(It diRemw from Owner Namc) OWNER HOME ADDRESS R a �` Sr• CITY S O,[Cr.,� Cp, . STATE zip OWNER MAILING ADDRESS Of different Rom Ownar Address) Attention or Care of YnG_ MAILING ADDRESS CITY STATE zJP TYPE OF 2WNERSHI1): CORPORATION INDMDUAL0 PAKINERSHIP❑ LOCALAGENCY❑ COUNTYAGENCYQ STATE AGENCY❑ FEo AGENCY❑ OTHER❑ FACILITY FILE FAGLrrYID#: CO.OwNFR ID#: ACCOUNT ID#; COMPLETE THE FOLLOWING BU$IN SSF CILITY INFORMATION: rr-ry� Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENTt YES NO 4 IS Oils an ExISTING Business LOCATION but a NEW TYPE Of regulated Business? `TES ❑ NO BUSINESS/FACILITY NAME(Thiswill be the BUsINCSS NAMEon the HEALTH PERMIT) �2olJGT'I Jam. OQ tRYJ , I P FACIUTY ADDRESS(IfFAourrls a MomEF0004.1wor F000 VemeLE,use the rrvs"^Q`W-•"•^0 r'a1 BUSINESS PHONE '3 �'2�YY10 S1 saxes CRY(If FAGArn'Is a MOIa[f F000 tlMrer F000 tRraQl-file the rM^"""O1 rrtvt cQ.TE zip 9saI6; " BOARD OF SUPERVISOR DISTRICT LOCATION CODE Key! KEY2 wiuNG ADDRESS for Health Permit(If DIFFERENTfmm FaddyAddross) ADantlon W Care Of 1 - MAILING ADDRESS CITY STATE ZIP SIC OWE: �� APNo! GeMIMHr: Arr._nrlNTa DRESS_forfees and charges: OWNER ❑ FACILITY/BUSINESS BII I Nr AND rOmf t ANrF. A r"riwi FnrXFt[1 1, the undersigned Applicant, certify that 1 am the Owner, Operator, or Aothoriad Agent of this Business,and 1 acknowledge that all Pt3RMwrj F Ess,Pr.NArmrav,ENr•ORCFprENr Cumn; S and/or HOURLY Culacss assodated with this operation will be billed to me at the address identified above as the ACCOUNTAL2129Ass for this site. I also certify that all information provided on this application is true and correct; and that all regulated 2Mivltic3 will be performed In accordance with all applicable SAN JOAQum CoLIN'rY Ordinance Codes and/or Standards and STATR and/or MKRArl.aws-and Re ulatens: APPLICANT NAME: Irj>= 'a) ,L-L,-Fr SIGNATURE' TITLE: MINI /II V(T,i OIC A//�JN O't^� /l� Oo DRIVERS LIC NSE Approved By Date Q' ( �$ Accounting Office Processing Completed By Data (� A PROGRAM(EHD 48-02-034 Pink)or WATER SYSTEM(EHD 45-02003)form must be completed for each EHD regulated operation at this I(KATION except UST Program(Use SWRCB forms) EI-ID 48-02-035 Masterfile Ro=d-Green 10/92003