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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> r <br /> MASTERFILE RECORD INFORMATION FORM <br /> SHADED SECTIONS FOR EHD USE ONLY OWNERID# CASE# <br /> OWNER FILE <br /> COMPLETETHEFOLLOWINGBUSINESS OWNER INFORMA770N.' CHECKIF OWNER CURRENrzyGNNLEwrTHEHD❑ <br /> BUSINESS Deilani Leyva PHONE: <br /> OWNER'S NAME Pit MI Last 209-915-2765 <br /> BUSINESS NAME(If different fmmowner Nemo) Soo Seo orTax ID# <br /> Dulce's by Deilani 571-59-0693 <br /> OWNER'S HOME ADDRESS 9426 Bonanza Dr <br /> clrStockton STA'CA zIP95209 <br /> OWNER'SMAILINOADDRESS (If different from Owner's Address) Atientlon orcere of <br /> MAILING ADDRESS CITY STATE zip <br /> T'PE OF OWNERSHIP: <br /> CORPORATION❑ INDIVIDUAL® PARTNERSHIP❑ LGOALAGENOY❑ COUNTY AGENCY❑ STATE AGENCY C FED AGENCY_ I OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID#: CO.OWNER ID M ACCOUNT ID#: <br /> COMPLETETHEFOLLOwNG BUSINESS FACILITY INFORMATJON: <br /> Is this a NEW BUslness LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO <br /> Is this an EXISTING Business LOCATION but a NEW T'PE of regulated Business? YES ❑ NO yJ <br /> BUSINESS/FACILIT'NAME(This will be the BMNEssNa Eon the HEALTH PERMIT) <br /> Dulce's by Deilani <br /> FACILITY ADDRESS(B FACILfrYIS a MOBILEFODo UNtror F000 VEIectEuse the COMMISSARY AWREsst BUSINESS PHONE <br /> 9426 Bonanza Dr 209-915-2765 <br /> Suite# <br /> CITY(if FAaLITYIs a MostLE FOOD UMror F000 VEwctE uJJIItheSTATE zip <br /> thC Mss <br /> CA 95209 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> MAILING ADDRESS for Health Permlt(If D/FFERENTfrom Facility Address) Attention orCare Or <br /> MAILING ADDRESS CITY STATE zip <br /> SICCODE: APN P. Co "r: <br /> ACCOUNTADORE86for fees and charges: OWNER ® 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 I <br /> acknowledge that all PERMIT FEES, PENALTIES, ENFORCEMENT CHARGES and/or HOURLY CHARGES associated With this Operation will be billed t0 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 JOAGUIN COUNTY Ordinance Codes and/or Standards and STATE and/or FEDERAL <br /> Laws and Regulations. <br /> APPLICANT'S NAME: Deilani Leyva SIGNATURE: <br /> Please Print <br /> TITLE: Owner DATE 08/23/2021 DRIVER'S LICENSE# Wim '��T t<cj l <br /> PHOTOCOPY REQUIRED) D <br /> Approved By Date Accounting Office Proceaeing 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 forma) <br /> EHD 48-02-035 Masterfile Record-Green <br /> 11127107 <br />