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0 0 <br /> SAN.JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> SHADEDSECT/ONs FOR EHD USE ONLY OWNERID# CASE# <br /> OWNER FILE <br /> COMPLETE THEFOLLOH?NOBUSINESS OWNER INFORMATION., CHECK/F OWNER CURRENTLVONFxEwIrjHEHD❑ <br /> BUSINESS San Joaquin Delta Communi y Cc lege PHONE:209 954 5835— <br /> OWNER I s <br /> 835OWNER'S NAME <br /> First MI Last <br /> BUSINESS NAME(If diA'erent fromOwner Name) See Sec orTax ID it <br /> 94-1044400 <br /> OWNERS HOME ADDRESS 5151 Pacific Avenue <br /> CITY Stockton STATsA ZIP 95207 <br /> OWNER'S MAILING ADDRESS(If different fromOwner'a Address) Attention orCare of <br /> 5151 Pacific Avenue Stacy Pinola <br /> MAILING ADDRESS CITY 5151 Pacific Ave STA LP 95207 <br /> TYPEOFOWNERSHIP: <br /> CORPORATION[:] INDIVIDUAL[I PARTNERSHIP El LOCALAGENCY❑ COUNTYAGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER <br /> FACILITY FILE <br /> FACILITY ID M CO-OWNER ID M ACCOUNT ID#: <br /> COMPLETETHEFOLLOW,VO BUSINESS FACILITY INFORMAnom <br /> ' <br /> Is this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑Q NO ❑ <br /> Is this an ExISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ NO 13 <br /> BUSINESS/FACILTy NAME(This will be the BuamssaAkaron the HEALTH PERMIT) <br /> San Joaquin Delta College South Cam us at Mountain House <br /> FACILITY ADDRESS INFAOaJ/Yle a MOeaEFOODLWTGr FOOD I/waruse the COMMISSARY ADDRESS) BUSINESS PHONE <br /> 2073 South Central Parkway 209 954 5835 <br /> Suite# <br /> CITY(if FAmrwis a MowLeF000 UNnor FOOD VEHICLE use the Cammtssa CrtYI STATE 7iP <br /> Mountain House CA 95391 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> MAJUNGADDRESSforHeBft Pbtm1t(If OlFFERENTfmm FacifityAddress) Attention orCarsOf <br /> 5151 Pacific Avenue Stacy Pinola <br /> MAILING ADDRESS CIN 5151 Pacific Avenue STATE CA 7JP 95207 <br /> SIC CODE: APN ik CONttZ <br /> AT+riouNTA00RESS-for fees and charges: OWNER ® FACILITYIBUSINESS ❑ <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner,Operator.or Authorized Agent of this Business,and <br /> acknowledge that all PERMIT FEES,PENALTIES,ENFORCEMENT CHARGES andler HOURLY CHARGES associated with this operation will be billed to me at the <br /> address Identified above as the ACCOUwADDRESS for this site. I also certify that all information provided is applicati is true and correct;and that all <br /> regulated activities will be performed In accordance with all applicable SAN JOAOUIN COUNTY Ordinan 1TIs a or n rds a STATE and/Or FEDERAL <br /> Laws and Regulations. <br /> APPLICANT'S NAME: Stacy Pinola SIGNATURE <br /> please PNnt r� 12/4/12 <br /> TITLE: Facilities Planner/Envirorunental/GrA%ks Manager PIER'HOTOS LICE QUIRED <br /> Approved By Date Accounting Office Processing Completed By Date <br /> A PROGRAM(EHD 48-02-034 Pink)or WATER SYSTEM(EHD 48-02-003)form must be completed for each END regulated operation at this LOCATION <br /> except UST Program(Use SWRCB forms) <br /> EHD 48-02-035 Masterfile Record-Green <br /> 11/27/07 <br />