ENVIRONMENTAL HEALTH BRANCH
1390 Market Street, Suite 210, San Francisco, CA 94102
Phone 415-252-3800 | Fax 415-252-3875
BUSINESS CLOSURE FORM
Permit Type(s): (check all that apply)
Permit/ID #
Permit/ID #
Permit/ID #
Food Facility
Massage
Water
Laundry
Body Arts
Pool
Pet facility
Medical Cannabis
Well
Tobacco
Weights & Measures
Solid Waste
Other
If applicable, SF Tax Collector Business Account Number (BAN):
Business Name (DBA):________________________________________________________________________________
Business Address: ___________________________________________________________________________________
Date of Closure: ______________________
Sole Owner Partnership Corporation LLC LP Other ________________
Ownership name: __________________________________________________________________________________
Phone #: ________________________________ Email: _________________________________________________
________________________________ ________________________________ ____________________
Print Name (Owner, officer, or authorized agent) Signature (Owner, officer, or authorized agent) Date
I understand that this declaration is subject to review by the Department of Public Health, Environmental Health. I declare under
penalty of perjury that I am an authorized representative of this business entity and that the information contained herein is true
and complete to the best of my knowledge and belief.
For Department of Public Health Office Use Only
BRC/BAN#: ________________________ Class: ________ Account: _________________ Permit/ID: ___________________
Verified closed during site visit conducted on ______________________.
Per Tax Collector database, business and/or BAN closed effective_________________. This document is for EH record purposes.
Notes: ______________________________________________________________________________________________________
__________________________________________ ___________________________ Reviewed by: __________
Inspector Date
Date:
Notes:
City and County of San Francisco
DEPARTMENT OF PUBLIC HEALTH
ENVIRONMENTAL HEALTH
click to sign
signature
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