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I SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT" <br /> MASTERFILE RECORD INFORMATION FORM <br /> �� <br /> 1 �aZDEDSECTIONSFOREHDUSEONLY OWNER ID# �I l.� CASE# C)�� <br /> I 520U�I.d� F-, <br /> OWNER FILE <br /> COMPLETE THEFOLLOW/NG BUSINESS OWNER/NFORMATlow CHECK/F OWNER CURRENTLYONF/LEW/TH EH D❑ <br /> BUSINESS PHONE: <br /> OWNER'S NAME <br /> First MI Last <br /> BUSINESS NAME(If different from owner Name) See Sec orTax ID# <br /> Pacific Gas & Electric Company <br /> OWNER'S HOME ADDRESS 3401 Crow Canyon Road <br /> CITY San Ramon, CA 8rarE <br /> CA ZIP94583 <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 9 INDIVIDUAL❑ PARTNERSHIP❑ LOCALAGENCY❑ COUNTY AGENCY❑ STAT AGENCY❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID#: (� <br /> 1':?0 1 KO S2 D ACCOUNT ID#: 6339'3i <br /> COMPLETETHEFOLLOW/NG BUSINESS FACILITY/NFORMATlow <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 /> BUSINESS/FACILITY NAME(This will be the BUSINESSMAMEOn the HEALTH PERMIT) VACANTLOT <br /> FACILITY ADDRESS(lf FACILnyIs a MOBILEFOOD UNITor FOOD UEHICLEUse the COMMISSARYADDRESS) BUSINESS PHONE <br /> 712 South Sacramento Street <br /> StreetNumber viryction Street Alamo Street Suite# <br /> CITY(If FAai_rrris a MOBILE FOOD UNrror FOOD VEHICLE use the COMMISSARY CITYLodi STATE CA zip 65240 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> MAILING ADDRESSforHealthPermit(IfDIFFERENTfromFaci/ityAddress) Attention crCare Of Rick McCartney <br /> Terra Pacific Group <br /> MAILING ADDRESSClTY201 North Civic Drive, Suite 135, Walnut Creek STATE CA ziP94596 <br /> SIC CODE: APN#:04'55-32-RUO COMMENT: <br /> U Zn <br /> ACCOUNTADDRESS for fees and charges: OWNER Q FACILITY/BUSINESS ❑ <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 and/or HOURLY CHARGES associated with this Operation WIII 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' ILA2G�i�i L SLS r Get SIGNATURE: <br /> Please Print <br /> TITLE: VER'S UCENS <br /> �I�Lf t _ J�� <1 DATE J L L /Lt)/"Z PHIOTOCOPY REQUI ED <br /> Approved By <br /> Date Accounting Office Processing Completed By V 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) pe- ;)-`f S-19 <br /> EHD 48-02-035 Masterfile Record-Green <br /> 1-1127107 <br />