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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> C <br /> SHADED SECTIONS FOR END USE OIILY ) OWNER ID ASE <br /> 01 ,'1 30 �n—moi— __#,_ --�'— <br /> OWNER FILE v <br /> COMPLETE THEFOLLOWfNG BUSINESS OWNER INFORMA rION.' CHECK IF OWNER CuRRENrt YON Fite WITH SHOD <br /> BUS ES NAMEpfdRercnt/rxaowvw Name — __ Lut 'Soe See wTax lO# PHONE: <br /> OWNERrSNAME <br /> [Saybrook <br /> i 650-6324522 <br /> Same 46-7916366 <br /> OWNER'S HOME ADDRESS 303 Twin Dolphin Drive.,Suite 600 <br /> CITY Redwood Shores STATECAzip 94065 <br /> OWNER'SMAILINGADDRESS (if different fo owner's Address) Atttentlonar Camof --- I <br /> Same Jeffrey M.Wilson I <br /> MAILING ADDRESS CITY - rSTATE ZIP <br /> TYPE OF Owxea9HIP: <br /> CORPORATION El INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY El COUNTY AGENCY El STATE AGENCY FED AGENCY OTHER' <br /> FACILITY FILE <br /> FAaLRYID#: Q -2Lf151 Co.OmERID#: — - A.._I AccGUNTID#: A/L0O <br /> ComPLEYE mrmuowivil BUSINESS FACILITY INFORMA770W ryy� <br /> jI Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES El No LJ <br /> rt�n.a�an<u-/l <br /> Is this an EXISTING Business LOCATION but a NEw TYPE of regulated Business? YES El NOZI <br /> BUSINESsfFACILW NAME(This will b Naal lhTE �HH PEe;IT) <br /> S b k rC � KC ��U I <br /> FACILITv ADDRESS(NFAc/,,rise Mo eFood UNrrer Fora Vee iEuM agg. jip—aa%AmB£) BUSINESS PHONE <br /> 783 Spartan Way 650-632-4522 <br /> also___ snwe Nan,e sueea _-- <br /> CITY(it FAOurYls a Moeas FOOD Urerw Feet,vleac s ase the CoiwlssARY CnvI STATE I ZIP <br /> Lathrop CA 95330 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE 7 KEY1 KEY2 <br /> MAILINGADDRESS for Health Permltllf OIFFEReNrfrem Facdity Address) Attention wCare Of <br /> 303 Twin Dolphin Drive,Suite 600 Saybrook CLSP,LLC Attn: Jeffrey M.Wilson <br /> SMAILING ADDRESS CITY I STATE I ZIP40 <br /> Redwood Shores ®�CA 965,..._ <br /> IC Cci APN#: Cov"Est: I <br /> 49QQQ-(/-yZAQpBCS for fees and charges: OWNER D FACILITYIBUSINESS _f <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and <br /> I acknowledge that all PERMIT FEES,PENALTIES,ENFORCEMENT CHARGES andfor HOURLY CHARGES associated with this Operation will be billed to me at the <br /> address Identified above as the Accouwr ADOREss for this site. I also certiy 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 JOAaUIN COUNTY Ordinance Codes andlor Standards and STATE andfor <br /> FEDERAL Laws and Regulations. <br /> r <br /> APPLICANT'S NAME:Saybrook CSLP,LLC,By:Saybrook Fund Investors,managing member'SIGNATURE: <br /> F%aaas Print <br /> TITLE: Jeffrey M,Wilson,Officer DATE 1/30/18 PHO•CO"REQUIRED <br /> APPrwad BY .11r-"..-IngCompbtAa By l V.I. <br /> A PROGRAM{EHD 48-02-034 Pink)or WATER SYSTEM(EHD 46-02-003)form must be completed for each EHO regulated operation at this LOCATION <br /> except UST Program(Use SWRCB forms) <br /> EHO 48-02-035 Masterfile Record-Green <br /> 8119108 <br />