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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM SHADEDSECt/ONS FOR EHD USE ONLY OWNER ID# rot 1 Our-, ?—/ CASE# OWNER FILE COMPLETE THEFOLLOw7NGBUSI NESS OWNER INFORMATION: CHECKIF OWNER CURRENrc YONFiLEWITH EHD❑ BUSINESS San Joaquin Delta Communi y Co lege PHONE:209 954 5835 OWNER'S NAME First MI Last BUSINESS NAME(If d%rferent fromOvmar Name) Soo Seo orTaX ID# 94-1044400 OWNER'SHOMEADDRESS 5151 Pacific Avenue CITY Stockton STAT& ZIP 95207 OWNER'S MAILING ADDRESS(If differentfromOwneesAddressl Attention arcane of 5151 Pacific Avenue Stacy Pinola MAILING ADDRESS CITY 5151 Pacific Ave STAFA ZIP 95207 TYPEOFOWNERMIP: CORPORATION El INDIVIDUAL El PARTNERSHIP F1 LOCALAGENCY❑ COUNTY AGENCY El STATE AGENCY FED AGENCY❑ OTHER[] FACILITY FILE FACILITYID#: SIJ �� CO-OWNERID#: ACCOUNT ID#: COMPLETE THEFOLLOWNG BUSINESS FACILITY INFORMAT/ON.' IS this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑x NO ❑ Is this an EXISTING Business LOCATION but a NEWTYPE of regulated Business? YES ❑ NO BUSINESS/FAOILT'NAME(This will be the BOSINesaNAYEon the HEALTH PERMIT) San Joaquin Delta College South Cam us at Mountain House FACILITY ADDRESS(If FACtusYle a MOBILEFOODUMTOr I"VE=Fuse the CommisuRYAWREsal BUSINESS PHONE 2073 South Central Parkway 209 954 5835 Sufte# CITY(If FAcnme a MoeneFooDUwror F000 VEHIcL me the Commissura Crtrl STATE ZIP Mountain House CA 95391 BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 MAtUNO ADDRESS for Heal Permitpf DIFFERENTfrom Facility A ddress) Attentlon OrCare Of 5151 Pacific Avenue Stacy Pinola MAILING ADDRESS CIN STATE CA ZP 95207 5151 Pacific Avenue SIC CODE. APN#: CommFM: ACCOUNTADDRE$$for fees and charges: OWNER ® FACILITY/BUSINESS ❑ BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner,Operator.or Authorized Agent of this Business,and 1 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 ACCOUNTADDRESS for this site. I also certify that all information provided o Is applicati is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Online 6 s a or and Ids a STATE and/or FEDEaAL Laws and Regulations. APPLICANT'S NAME: Stacy Pinola SIGNATURE Please Print 12/4/12 TITLE: Facilities Planner/Environmental/GrANTManager DRIVER'S LICENSE# PHOTOCOPY REQUIRED Approved By Date Accounting Office Processing Completed By Dafa A PROGRAM(EHD 48-02-034 Pink)or WATER SYSTEM(EHD 40-02-0031 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