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SAN JOAI N COUNTY ENVIRONMENTAL HEALTH D RTMENT ATERFILE RECORD INFORMATION FO SHADED SECTIONS FOR EHD USE ONLY OWNERID#.' © t 1. O �'.' CASE# OWNER FILE COMPLETE 7HEFOLLOH9NG BUSINESS OWNER tNFORMA77aw CNECK IF OWNER CURRENTL YONFiLE wiTHEHD❑ BUSINESS PHONE: MILA S PADILLA (209) 832-7780 OWNER'sNAME Firsf MI Last BUSINESS NAME(If diRerentfmmowner Name) Soc Sec orTax ID# OWNER'S HOME ADDRESS PO BOX 1036 CITY Tracy STATE ZIP 95378-1036 OWNER'S MAILING ADDRESS(If different fromOwner's Address) Attention orCare of MAILING ADDRESS CITY STATE ZIP TYPEOF OWNERSHIP: CORPORATION❑ INDIVIDUAL El PARTNERSHIP❑ LOCAL AGENCY[I COUNTYAGENCY❑ STATEAGENCY❑ FED AGENCY[I OTHER❑ FACILITY FILE FACILITY ID#: / " CO-OWNERID#: ACCOUNT ID#: COMPLETE7HEFOLLOH4NG BUSINESS FACILITY tNFORMAnow Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES E NO EX Is this an ExiSTING Business LOCATION but a NEW TYPE of regulated Business? YES ® NO E BUSINESS/FACILITY NAME(This will be the BusikE Masson the HEALTH PERMIT) Padilla Property FACILITY ADDRESS(if FAOis a MOHILEFOOo UNiror Foot,VEH/CLEUSe the COMMISSARY ADDRESS) BUSINESSPHONE 14749 N THORNTON RD (209) 832-7780 Suite# CITY(If FActtrr'Is a MOWLEFow UNaor FooD VEHICLE use the CoMMlssPRY CIM STATE ZIP LODI CA 95242-9509 BOAROOF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 MAILING ADDRESS forHeatth Pef mlt(If D/FFERENTfrom FacilifflAddress) Attention orCare Of PO BOX 1036 Andy Zarakani MAILING ADDRESS CITY TRACY STATE CA ZIP 95378-1036 SIC CODE: APN#; �� Z�' COMMENT: ACCOLINTADDRESS forfees and charges: OWNER a❑ FACILITYIBUSINESS ❑ BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner, Operator,or Authorized Agent of this Business,and I acknowledge that all PERMIT FEES, PENALTIES, ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this Operation will be billed to me at the 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 regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or FEDERAL Laws and Regulations. APPLICANT'S NAME: Mila Padilla SIGNATURE: Please Print TITLE: Property Owner DATE PHIVER'SUCENSOTOOOPY AIRED ed.I By A �1 t Dote CI AOeountlng OH4IO PracIsing C iw BY: '';I •'PsIrT nY.l' Ie K .°43 '2 .h t a: 4 A PROGRAM(EHD 48-02-034 Pink)or WATER SYSTEM(EHD 48.02-003)form must be completed for ea VPlq H:airfitda 161WAA1 at this LOCATION except UST Program(Use SWRCB forma) _ EHD48-02-035 • - Masterfile Record-Green 11/27107