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a <br /> SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> 5-eQ�,�BY/a <br /> SHADED SEcTIDPlSFOREHDUSEONLY OWNER ID# �U CASE# rj�C� e,aqt 771 <br /> OWNER FILE <br /> COMPLETETHEFOLLOW/NG BUSINESS OWNER/NFORMATlom CHECKIFOWNER CURRENTLYON FILE WITHEHD❑ <br /> BUSINESS PHONE: <br /> OWNER'S NAME <br /> First Ml Last <br /> BUSINESS NAME(If different from Owner Name) Sac Sec orTax ID# <br /> Pacific Gas & Electric Company <br /> OWNER'S HOME ADDRESS 3401 Crow Canyon Road <br /> CITY San Ramon, CASTATE ZIP 94583 <br /> OWNER'S MAILING ADDRESS (If different from Owner's Address) Attention orCare of Rudy I V IIIIan <br /> MAILING ADDRESS CITY STATE ZIP <br /> TYPE OF OWNERSHIP: <br /> CORPORATION[] INDIVIDUAL❑ PARTNERSHIP❑ LOCALAGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ <br /> FACILITY^ FILE,, �-7Cl(. (� <br /> FACILITY ID#: (70 i (7(� NER I — 20 SOLI v ACCOUNT ID#: ()C17 ((�� <br /> COMPLETETHEFOLLOW/NG BUSINESS FACILITY/NFORMATlom <br /> Is this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No ■❑ <br /> Is this an ExISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No <br /> BUSINESSIFACILITY NAME(This will be the SusnvEsslVAmEon the HEALTH PERMIT) /'1�V VAC n n I T L®T <br /> FACILITY ADDRESS(NFAc1LnYls a MOBILEFOOD UN/Tor FOOD VEHIcLEuse the COMMISSARY ADDRESS) BUSINESS PHONE <br /> 712 South Sacramento Street <br /> i t o a e S—t Two Suite# <br /> CITY(If FActurvls a MOBILE FOOD UNIT or FOOD VEHICLE use the COMMISSARY CIN)Lodi <br /> STATE CA ZIP 65240 <br /> BOARD OF SUPERVISOR DISTRICT -( LOCATION CODE KEY1 KEY2 <br /> MAILING ADDRESS fOr Health PelM/t(If DIFFERENTfrom FacilityAddress) Attention orCare Of Rick k p fl CC a rt n ey <br /> Terra Pacific Group f� IVI G <br /> MAILING ADDRESSCITY201 North CIVIC Drive, Suite 135, Walnut Creek STATE CA 1z'P94596 <br /> SIC CODE: APN#:045-32-400 COMMENT: <br /> U �-U <br /> ACCOUNTADDRESS for fees and charges: OWNER ❑■ FACILITY/BUSINESS ❑ <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and 1 <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 /> c <br /> APPLICANT'S NAME:, ZLA2 Y1tJ7SG3 r C'9 SIGNATURE: a <br /> Please Print <br /> TITLE' �a(� Z.✓ ry� DATE t../- lip/'Z. DRIVER'S LICENSE# <br /> PHOTOCOPY REQUI ED <br /> Approved By Date Accounting Office Processing Completed By VDI <br /> Date <br /> / 3 ji <br /> A PROGRAM(EHD 48-02-034 Pink)or WATER SYSTEM(EHD 46-02-003)form must be completed for each EHD regulated 7m6asterfile <br /> ration at this LOCATION <br /> except UST Program(Use SWRCS forms) 911-7 <br /> EHD 48-02-035 Record Green <br /> 11/27/07 <br />