MUNICPIO DE SO BERNARDO DO CAMPO

SECRETARIA DE SADE
Departamento de Proteo Sade e Vigilncias SS-4

FORMULRIO DE PETIO DA VIGILNCIA SANITRIA

Assunto:
Licena Sanitria Simples Laudo Tcnico de Avaliao - LTA
Licena Sanitria Inicial Veculos
Renovao de Licena Sanitria Equipamentos
Encerramento de Atividade Recurso/Defesa ______________________________
Responsabilidade Tcnica - Assuno Alterao de ____________________________________
Responsabilidade Tcnica - Baixa Outros ____________________________________________

IDENTIFICAO DA EMPRESA/ESTABELECIMENTO (preenchimento obrigatrio)

Raza o Social: _________________________________________________________________________________________________________________________________
Nome Fantasia: ______________________________________________________________________________________________________________________________
CNPJ/CPF: _____________________________________________________________________________________________________________________________________
Endereo: __________________________________________________________________________________________________________________n _________
Complemento: ___________ Bairro: __________________________________________________________________CEP: ___________________
Fone/fax: _______________________________ E-mail: ______________________________________________________________________________________
Hora rio de Funcionamento: : a s : horas
Processo SBC n: ___________________________________________________________
Inscria o Mobilia ria: _____________________________________ Inscria o Imobilia ria ____________________________________________
CARACTERIZAO DA EMPRESA/ESTABELECIMENTO
Ramo De Atividade: ________________________________________________________________________________________________________________________
N CNAE: ______________________________________________________________________________________________________________________________________
Principal Atividade Desenvolvida: ____________________________________________________________________________________________________

RESPONSVEL TCNICO - ASSUNO

Nome: __________________________________________________________________________________________________________________________________________
CPF: ___________________________________________________ Registro Profissional CR n _____________________________________
Fone: Cel.: E-mail: __________________________________________________________________________
Hora rio de Trabalho: : a s : horas
RESPONSVEL TCNICO - BAIXA
Nome: __________________________________________________________________________________________________________________________________________
CPF__________________________________________ Registro Profissional CR n __________________________________
Fone: ____________________ Cel.: ________________ E-mail: ________________________________________________________________________
RESPONSVEL LEGAL (preenchimento obrigatrio)
Nome: __________________________________________________________________________________________________________________________________________
CPF: CEP: Fone: Cel.: _______________________
E-mail: _________________________________________________________________________________________________________________________________________
CONTATO DA CONTABILIDADE
Nome do Contador: ________________________________________________________________________________________________________________________
Endereo da Contabilidade: ___________________________________________________________________________________________ n ______
Fone: Cel.: E-mail: ______________________________________________________________
Observaes: ______________________________________________________________________________

Nome do Responsa vel Legal/Procurador: _________________________________________________________________________________________

Assinatura: _______________________________________________________________________________________________________________
Data: / /