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SHADED SECTIONS FOR EHD USE ONL Y SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM OWNER ID# V(L/w�� CASE# OWNER FILE COMPLETE THE FOLLOW/NG BUSINESS OWNER /NFORMAT/ON.CHECK 1F OW NER CURRENTL Y oN FiLE wiTH EH DF7 BUSINESS Mike (Paul Konzen other owne) YES ❑ NO ZI Barry PHONE: Mike Paul OWNER'S NAME FACILITY ADDRESS (If FAciLmis a MOBILEFOOD UNITor FOOD VEHICLEuse the COMMISSARY ADDRESS) BUSINESS PHONE 209-495-8777, 652-5222 209-232-3582 Suite # First MI Last STATE BUSINESS NAME (If different from Owner Name) OWNER'S HOME ADDRESS 5509 Langworth Road CITY Oakdale STA LA ZIP 95361 OWNER'S MAILING ADDRESS (If different fromOwner's Address) Attention orCare of 5707 Lan worth Road Scott Baker 652-6196, or Salina Soto MAILING ADDRESS CITY STAT IbA� ZIP Oakdale 95361 TYPE OF OWNERSHIP: CORPORATION ® INDIVIDUAL ❑ PARTNERSHIP ❑ LOCAL AGENCY ❑ COUNTY AGENCY ❑ STATE AGENCY ❑ FED AGENCY ❑ OTHER ❑ FACILITY FILE FACILITY ID#: tv2- -77 CO-OWNER ID#: ACCOUNTID#: rT^Ob��olo� COMPLETETHEFOLLOW/NG BUSINESS FACILITY /NFORMAT/ON: 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 ZI BUSINESS/FACILITY NAME (This will be the BUS/NESSNAMEOn the HEALTH PERMIT) Central valley Ag Grinding FACILITY ADDRESS (If FAciLmis a MOBILEFOOD UNITor FOOD VEHICLEuse the COMMISSARY ADDRESS) BUSINESS PHONE 26 Hooper Drive 209-232-3582 Suite # CITY (if FACILITYIS a MOBILE FOOD UNIT Or FOOD VEHICLE use the COMMISSARY CITY) STATE ZIP Stockton CA 95203 BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 MAILING ADDRESS fOiHeaith PefM t(lf D/FFERENTfrom Facility Address) Attention orCare Of 5507 Lan worth Drive Scott Baker or Salina Soto MAILING ADDRESS CITY STATE CA zip 95361 Oakdale SIC CODE: 4221 APN#: I COMMENT: Farm Product Warehousing and Storage ACCOUNTADDRESS for fees and charges: OWNER ❑X FACILITY/BUSINESS ❑ 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 t0 me at the address identified above as the ACCOUNTADOREss 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 applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or FEDERAL Laws and Regulations. APPLICANT'S NAME: Scott Baker SIGNATURE: Please Print TITLE: Consultant to Central Valley Ag Grinding DATE 3/30/16 DRIVER'S LICENSE# PHOTOCOPY REQUIRED Approved By Date Accounting Offlce Processing Completed By / j � 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 11/27/07