BILLING - Laserfiche WebLink

Home Browse Search

SAN JO*N COUNTY ENVIRONMENTAL HEALTH DORTMENT MASTERFILE RECORD INFORMATION FORM SHALIEL1SECTlONSFOREHDUSEONLY OWNERID# CASE# , OWNER FILE COMPLETE rHEFOLLOwlNG BUSINESS OWNER INFORMATION.' CHECK lF OWNER CuRRENTG YON FILE WITH EHD❑ BUSINESSY 4 c ��lc>t� PHONE: OWNER'S NAME First Mt Last BUSINESS NAME(if differant from Owner Name) Soc o orTax ID# �7 A,VOL r 1 OWNER'S HOME ADDRESS {� � � �t✓� y- Ai 22-Lo CITY �eCr� $. E ZIFMcx, a T^ L OWNER'S MAILING ADDRESS (If different from Owners Address) Attention orCare of •o J MAILING ADDRESS CITY STATE ZIP TYPE OF OWNERSHIP: 2'_CORPORATION El INDIVIDUAL 2 PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ FACILITY FILE FACILITY ID#: CO-OWNER ID#: ACCOUNT ID#: CO/NPLETE7HEFOLLOwm BUSINESS FACILITY INFORMATION: 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 NEwTYPE of regulated Business? YES ❑ No I BUSINESS/FACILITY NAME(This will be the 8usnvESSNAmEan the HEALTH PERMIT) r, a �& ' �LA FACILITY ADDRESS(IfrActurrlsa 6axrFooaU1vtrorFOOD✓EHmeuSetheCommissAgYAOPRESS) BUSINESS PHONE roti ! Y)v r-k n r. Lao Ci Lt�• �t''� R Suite# CITY(if FAcrurylsaMosrLEFo0DUNrrerFOOD VEHicceuse the CQMMIssARYCrrr1 STATE ZIP BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 MAILING ADDRESS for Health Permlt(If DIFFERENTfrom FacilityAddress) Attention orCars Of MAILING ADDRESS CITY 7STATE ZIP SIC CODE: APN#: COMMEKr ACCoUNTAp BE_&S farfees and charges: OWNER ❑ FACILITYl13US1NESS ❑ BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and i acknowledge that all PERMIT FEES,PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation will be billed to me at the address Identified above as the ACCOUNTADDREs5 for this site. l also certify that all information provided on this application Is true and correct;and that all regulated activities wile be performed In accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or FEDERAL Laws and Regulations. f , APPLICANT'S NAME: E r1 C.�/L 4_J I�� 1� SIGNATURET` � Please Print l TITLE: 1�K)%1) •-C I CATF,�I >� L i PHo-rocoPY REQUIRED h� Approved By j Date $1 i( Accounting OfficePrecasaing Completed By Date A PROGRAM(EHD 48-02-034 Pink)or WATER \\\SYSTEM(EHD 46-02-003)form must be completed for each EHD regulated operation at this LOCATION except UST Program(Use SWRCB forms) EHD 48-02-035 Masterfile Record-Green 11127107