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SAN JOA jr COUNTY ENVIRONMENTAL HEALTH ARTMENT <br /> STERFILE RECORD INFORMATION FO <br /> SHADED SECTIONS FOR EHD US£ONLY DWNER ID# CASE# <br /> OWNER FILE <br /> COMPLETE THEFOLLOw/NG B U S I NESS OW NER INFORMATION.' CHECK tF OWNER CURRENTLYONNLE w HEHD❑ <br /> BUSINESS Lauren Vigliotti <br /> OWNER'S NAME PHONE: 925-321-3291 <br /> First MI Last <br /> BUSINESS NAME(If different iromOwner Name) Soo Sec OrTax ID# <br /> Terraphase Engineering,Inc. <br /> OWNER'S HOME ADDRESS <br /> CITY Oakland STATEC ZIP 94612 <br /> OWNER'S MAILING ADDRESS(If different iromOWner's Address) Attention arCare of <br /> MAILING ADDRESS CITY STATE ZIP <br /> TYPEOFOWNERSHIP: <br /> CORPORATION® INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FEDAGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID#: CO-OWNER ID#: ACCOUNT ID#: <br /> COMPLETETHEFOLLOw/NG BUSINESS FACILITY INFORMATION.' <br /> �Ihisa'NEXW BNS{neSs LDQATIDN Or VEHICLE n02 pneV{OOSIy roguleted by the ENVIRONMENTAL HEALTH DEPARfMENT7 YES ❑ NO <br /> IsTING Business LOCATION but a NEIN TYPE of regulated Business? YES ❑ No <br /> BUSINE3s/FACILrrY NAME(This will be the Bu&NeasAkmEon the HEALTH PERMIT) <br /> FACILiYADDRESS(if FAa lsaMOBILEFDODUN/Tor FOODVEHICLEusetheCOMMISSARY ADDRESS) BUSINESS PHONE <br /> Corral Hollow Shopping Center, 1975 W 11th Street <br /> Suite# <br /> CITY(if FAciL is Mo&LE FOOD UNROr FOOD VEHICLE use the COMMISSARY CITY) STATE CA ZIP 95376 <br /> Tracy <br /> BOARD OF SUPERVISOR DISTRICT LOCATON CODE KEY1 KEY2 <br /> MAILING ADDRESS for Heald/Pemflt(If DIFFERENTfrom FacllilyAddress) Attention arcane Of <br /> MAILING ADDRESS CITY STATE ZIP <br /> SIC CODE: APN#: ^TZ 17o- 2, f CONMFM: <br /> ACCD ATADDRESS for fees and charges: OWNERX❑ FACIUTYIBUSINESS ❑ <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I <br /> acknowledge that all PERMIT FEES,PENALTIES, ENFORCEMENT CHARGES and/Or HOURLY CHARGES associated with this operation will be billed to me at the <br /> 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 <br /> regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or FEDERAL <br /> Laws and Regulations. <br /> APPLICANT'S NAME: Lauren Vigliotti SIGNATURE: t <br /> Please Print <br /> TITLE: Professional Geologist DATE 5/20/2013 DRIVER'S LICENSE# <br /> PHOTOCOPY REQUIRED <br /> Approved By Date Accounting Office Processing Completed By Date <br /> 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 <br /> except UST Program(Use SWRCB forms) <br /> EHD 4&02-035 Masterfile Record-Green <br /> 11/27/07 <br />