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12/19/2012 11:29 2090433 SJC.EHD LWTT 3 RECEID <br /> SAN JOAQUIN COUNTY EwRONIUENTAL HEALTH DEPARTMENT <br /> MAsTERRLE RECORD INFORMATION FORM DEC 2 6 2012 <br /> SUALInSECRaNB FOR EFJp UBEOMLy _ _ _ <br /> OWNER F!L! <br /> COMPLE( THEFOLLOININGBUSINe88 pWNER INFORMATION: CHedrtF OWNER CURaearrrtr OxFlLE wrT1iEHO <br /> BUSINESs r►rw PHONE: <br /> OWNER's NAME XMet i vl W <br /> 1 Nt <br /> BUSINmaNAhlE(Bdawaotaaaagwrrerfe ) sea orTgKlGax <br /> M I t� �/ - � p9� I <br /> OWNER'S Home Anmeas , wA <br /> CrtY C CA— 57� ZIP <br /> OWNER's MAILINGAbONEss (trdyfad grmmawneraAddren) AUen}Imr wt:areW <br /> MAILING Awma CITY _ STATE ZE <br /> IYPEbFOwN[paelP: <br /> ConpaRATION[..I INDIVMUAL&F PARTNERSHIP[] LtN1a,AGENOyO CouNTr AGENCY❑ STATEAOENCY[] l'eo AGs,,, OTHEK❑ <br /> FACILITY FINE n " <br /> COMPLETE THE FOLLOWING BUSINESS FAOILITY INFORMAnON; <br /> Ia Thlaa New aUah7laa LDUATION or VEHICLE not preVkQUSJY regUlated by the ENVIRONMENTAL HEALTH YES �y.l No ❑ <br /> le this an EmTIN6 Burmese LOCAT)ON beta NEw Typr of regulated aueimn7 Yea ❑ No rA <br /> Mu81NEWFACILITY NAME 0%6wai hevh gusma mwcothy HEALTH PERMIT) <br /> rrA u <br /> FACILITY AuI:ItEsa(NPAcsr ylS a ROoxLENbea uwrer FOeb Va aw asaa droCOp]�ssamAnoaEeal SU&NE89 PHONE <br /> I1ta } FjeSSem�r <br /> ------------- i- aU lQ .W5 <br /> riRY(YPFnuUrraa MbeasFbbD Urmar F00aVENUrstrsatha Coaals:Jtt+CIM SYATE <br /> Ccs C <br /> mmuNm Amnileo for Health PptTN%(Ir4/FFERkM'irore PiniityAan�vnal AU,antinn arOara pl <br /> MAILING ADOREas CITv STq'IE Ira <br /> RCG r;t ss for fees and charges; OWNERR: FACILITY/BUSINESSLuav pl <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the Undersigned Al caddy that i am tea Oamer,Operator,or AuMonzedAgent of this Bookteaa,and <br /> I acknowledge that all PERW FYeg,PpyiLT)ES,E")RCEMMT CHAttdes and/or HOURLYCHARrea aaSUOlafed whh MIS 6000 tlon will be billed to ma at the <br /> addrds Identned above as the AtxarxrAmgms for this%IW 1 6140❑ tN Ntnt All infbnra8ti0n provided on thi✓!aPPllcaden Is true and Carreet:and that <br /> all ragulyded activities will ba perforawd In A000rdgnce with ail app)ieabla SAN JOAGNIN COUNT(Orrllnan m Codes and/or Standard*and STATE and/or <br /> FmZRAL Lam and ulatipna. <br /> APPLICANT'S NAME: C `tel <br /> r(-.e� <br /> L7 SIGNATURE: <br /> Plewa PAnt <br /> Tme: <br /> DATE 1� / 2 DRIVER ELIC #I �L <br /> c -w4ar - <br /> A PROCRAM(EHO 48-02-084 P1Mc)Or WATER S"Taa(E1-4046-02-008)form mult be completed forgR2L EHD regulated uperatiun AtmiN 4QCAl1ON <br /> anept UST Program(Use SW cs fccj(..'�.'s) <br /> Sion 02035 �� ���,J � 11 (� � ��(,-�� MasteAlle ftecortl-Great <br />