Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> SHA DED SEC TIONS FOR EHD USEONLY OWNER ID# I�gl1--C <br /> ASE# St?C-3 <br /> OWNER FILE b �/ <br /> COMPLETETHEFOLLOW/NG BUSINESS OWNER INFORMAT/ON.' CHECKIF OWNER CURRENTLYON FILE WITHEHD❑ <br /> BUSINESS PHONE: <br /> OWNER'S NAME <br /> First MI Last <br /> BUSINESS NAME(If different from Owner Name) Soc Sec orTax ID# <br /> Pacific Gas & Electric Company <br /> OWNER'S HOME ADDRESS 3401 Crow Canyon Road <br /> CITY San Ramon, CA cSTATE ZIP 94583 <br /> OWNER'S MAILING ADDRESS (If different from Owner's Address) Attention orCare of Rudy Millan <br /> MAILING ADDRESS CITY STATE ZIP <br /> TYPE OF OWNERSHIP: <br /> CORPORATION❑■ INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE C <br /> , p I T� j <br /> FACILITY ID#: ;�� ID(Di (D l - NfiM - ll--D S2-'U AcCOUNT ID#: v U 3-�J`--3 <br /> COMPLETETHEFOLLOW/NG BUSINESS FACILITY INFORMATlow <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 /> BUsINES3/FACILITY NAME(This will be the BUS/NESSNAMEOn the HEALTH PERMIT) VACANT LOT <br /> FACILITY ADDRESS(If FAC/L/TYIs a MOBILEFOOD UNror FooD VEHICLEuse the COMMISSARY ADDRESS) BUSINESS PHONE <br /> 712 South Sacramento Street <br /> Suite# <br /> CITY(if FACIUTYIsaMOBILEFOODUNirorFOOD VEHICLE use the COMMISSARYCirt')Lodi— STATE CA <br /> ZIP 65240 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> MAILING ADDRESS for Health Peim/t(If DIFFERENTfrom FacilityAlddress) A Attention orCare Of Rick McCartney <br /> ey <br /> Terra Pacific Group <br /> MAILING ADDRESS CITY 201 North CIVIC Drive, Suite 135, Walnut Creek STATE CA z`94596 <br /> SIC CODE: APN#:045-32- 00 COMMENT: <br /> 7-o <br /> ACCOUNTADORESS for fees and charges: OWNER ❑■ FACILITY/BUSINESS ❑ <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: [,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 /> 7 <br /> APPLICANT'S NAME: 3nt-1?sUv r C SIGNATURE: <br /> Please Print <br /> TITLE: (all a e / ( DATE� L L L�/� PHOTOCOPY R QUI ED <br /> ✓)�l�1 fa l' ' <br /> RIVER'S LICENSE# <br /> F[Approved By Date Accounting Office Processing Completed By I jl 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) �C <br /> EHD 48-02-035 Masterfile Record tGreen <br /> 11/27/07 <br />