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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM SHADED SECTIONS FOR EHD USE ONLY OWNER ID# CASE# OWNER HILE C04ITLETETi-fEFOLLOiVIIVGBUS INESS OWN fNFolumT/ON' CHEcL;iF OWNER CURRENTLYONFILEv.1iTHEHD11 BUSINESS Patricia A Madrid GWNER'S NAME PHOtdE. (916) 308-5883 First MI Last BUSINESS NAME(If different from Owner Name) Sac Sec orTax ID# Castle of Candy 90-0455564 OWNER'S HOME ADDRESS 1433 W. Lockeford Street CITY Lodi STATE ZIP CA 95242 OININER'S MAILING ADDRESS (If different from Owner's Address) Attention or Care of MAILING ADDRESS CITY STATE ZIP i TYPE OF OWNERSHIP: CORPORAi.ON❑ INDIVIDUAL 0 PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY OTHER❑ j FACELITY FELE FACILITY ID#: CO-OWNER ID#: ACCOUNT ID#: COMPLETE THE FOLLOW/NG BUSINESS FACILITY INFORMATION: Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES NO ❑ A caw c-ru cur9 Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No BUSINESsIFACILITY NAME(This will be the BuswEssNAtrEon the HEALTH PERMIT) Castle of Candy FACILITY ADDRESS(If FAcILIrYis a MOBILEFODD UN/Tor FOOD VEHICLE USS the COMMISSARY ADORES S) BUSINESS PHONE 1433 W. Lockeford Street StreetNumber Direction Street Mame s Suite# (916) 308-5883 CITY(If FACILITY IS a MOBILE FOOD UNIT Or FOOD VEHICLE use the COMMISSARY CITY I STATE ZIP Lodi CA 95242 BOARD OF SUPERVISOR DISTRICT 4 LOCATION CODE KEY1I KEY2 MAILING ADDRESS for Health Permft(lf DIFFERENTfrom FacifityAddress) Attention orCare Of MAILING ADDRESS CITY STATE L'IP SIC CODE: APIN#: COMMENT: ACCOUNTADDRESS 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 I 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 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: Patricia Madrid SIGNATURE: Please Print TITLE: Owner DATE 10/3/2018 DRIVER'S LICENSE# N6614851 PHOTOCOPY REQUIRED FpprovedB y Date Accounting Office Processing Completed Sy 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 8119/08