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SAN JOAtztJIN COUNTY ENVIRONMENTAL HEALTH DErARTMENT <br /> ASTERFILE RECORD INFORMATION FG <br /> SHADED SEcnovs FOR EHO USE ONLY OWNER iD# CASE# <br /> OWNER FILE <br /> COMPLETE THE FOLLOWING BUSINESS OWNER/&FORMATION. CHEFS IF OW N E R CURRENTL rON FILE wire EHD❑ <br /> BUSINESS Crothall Laundry Services Manteca E PHONE: <br /> OWNER'S NAME 209-823-8965 <br /> First MI LazI <br /> BUSINESS NAME(If dWerarrt Pram Owner Name) Son Sec Of Tax ID# <br /> Crothall Laundry Services 16-1671901 <br /> OWNER'S HOME ADDRESS Publicly traded Corporation-there is no specific owner <br /> CITY Manteca STCJATE ZIP 95336 <br /> OWNER'S MAILING ADDRESS jN ahlearnt firm(ywner's Address) Attention orCare of <br /> Sheikh Mohd <br /> 2365 N.Airport Way <br /> MAILING ADDRESS CITY Manteca SCA Zip <br /> 95336 <br /> TYPE of OWNERSHIP: <br /> CORPORATION❑X INDIVIDUAL[I PARTNERSHIP❑ LOCAL AGENCY COUNTY AGENCY❑ STATE AGENCY El FED AGENCY Ormi <br /> FACILITY FILE0 4- `6--f-- <br /> FACIDTYID#: �n cCG-OWNER ID ti: AccouNT ID#: �f <br /> COMPLETE THE Fou OWING BUS)NESS FACT LITY INFORMATION: <br /> I5 this a NEW Busies Be LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES ® NO ❑ <br /> nce.e. u.o <br /> Is this an ExIsTiNG Business LOCATION but a NEW TYPE of regulated Business? YES ❑ NO ❑ <br /> BUSINESS/FACILITY NAME(This will be the HU3A FSSNAMEen the HEALTH PERMIT) <br /> Crothall Laundry Services-Manteca <br /> FACiLiTYADORESS(&FAC/umisamO&EFDODUNiror Food VFm LEthe COMa SSARYAOUREss} BUSINESS PHONE <br /> 2365 N.Airport Way/Manteca,CA/95336 209-823-8965 <br /> Swe# <br /> CITY(If FAci a mail"P000uvror Foco VEwct a the CowalssARY CnY) STATE ZIP <br /> 2365 N.Airport Way/Manteca,CA/95336 CA 95336 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEYI KEY2 <br /> MAILING ADDRESS IOr t"IeaNN7 PBrm/t(If DIFFERENTfrorn Facility Ad&v") Attention n Cam Of <br /> Sheikh Mohd <br /> 2365 N.Airport Way/Manteca,CA/95336 <br /> MAILING ADDRESS CITY STATE Zip 95336 <br /> 2365N Air ort Wa /MantecaCA/95336 CA <br /> SIC CODE: 7213 APN A: 198-030-33 CONMENr. <br /> BCCDUNTAODREss for fees and charges: OWNER ❑ FACILITY/BUSINESS a <br /> BILLING ANE)COMPLIANCE ACKNOWLEDGMENT. 1,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and <br /> I acknowledge that all PERM/TFEEs,PENALHes,ENFORCEMENT CHARGES and/or Homy CHARGES associated with this operation will be billed tome at the <br /> address identified above as the ACCOUNT ADDRESS for this site. I also certify that all information provided on this application is true and correct;and that <br /> all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE andlor <br /> FEDERAL Laws and Regulations. <br /> APPLICANT'S NAME: Ian Bigelow SIGNATURE: <br /> Please PNnt <br /> TITLE: VP-Engineering&Technical Services DATE 04/24/14 DRIVER'S LICENSE# Texas DL-07647439 <br /> PHOTOCOPY REQUIRED <br /> Appmred By Date AeoounlinB Grfico Prot ins Completed By oNs it <br /> A PNOGRAN-(EHD 48-02-034 Pink)or WATER SYSTEM(EHD 46.02409bform muqi completed for each EHD regulated operation at this L A <br /> except UST Program(Use SWRCB forms) 2-57 <br /> EHD 48-02-035 1-� 1,� Masterfile Record-Green <br /> 8119/08 V <br />