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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM SHADED SECfiDNs FDR EHD USE ONLY OWNERIDA 01000 p��IOs CASE# OWNER FILE CCAfRLETFTNEFCLLOW/NGBUSINESS OWNER/NFORMAnoN.' CHECKIF OWNER CURReMYONFILE*nwEHD❑ BUSINESS 51�.-k,b1� T'A1a�t,cGy mt-bQNL GQUU� PHON(E:: OWNER'S NAME IF, MI Lesr (�u BUSINESS NAYS(if dHlereathnmOwlwr Name) Soo Seo orTax ID 0 Gt(jjP Clu, wt-03U`),Vl OWNER'S HOME ADDRESS X151 IJ. Lp�IFoP.iJiA S�. CITY s^1C�1uiJ SLIATE ZIP OWNER'S MAILING ADDRESS(H d%Aareal rromOWlfer'a Address) Attention orCara of MAILING ADDRESS CITY STATE IJP TYPEGFOWNERsHIP. CORPORATION❑ kmvicUAL❑ PARTNERsHWEa LACALAGENCY❑ COUNTYAGENOY❑ STATEAGENCY❑ FEDAGENCY❑ OWER❑ FACILITY FILE FAcSUTYID#; Z)t) G/ CG-OWNERIDP ACCOUNTIDff:,%�,&5/495 CGMatETE7NEFouowne BUSINESS FACILITY/NFoRMAnov: Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES [ No ❑ Is this an ExlenMG Business LOCATION but a NEWTYPE of regulated Business? YES ❑ No ❑ BusiNE38IFAcury NAME(rhis will be the&MMMNAueon the HEALTH PERMIT) 5 rDckl of �P 7t1ut u Y AN�'1)I UL GROUP FAGUYYADDRESS fifFA=ff leaMoaAEF000UNIr Fool)Vr aEuaethaCDWISSARYAoonEss{ BUSINESS PHONE I� 1 ^� CA2r�U?N145 (�Dc)4Vl`(�yiI suae z CITY(IfFAcGurne a Mom.E Foi UNoorFDOa VEHICLE use the Commis YCItti STATE IJP S-1()rK-r CA G��G BOARD OF SUPumsDR DISTRICT LOCATTONCOOE KEY1 KEY2 MAIUNGAODREBS fOrHBR/Nf Pe/nI/LOf DIFFERENTfmm Fac/l/tyAdo'resgI Attention vCare t MAWNG ADDRESS CITY STATE IJP SICCODE: APIM CONRENr. . 11CCOUNT/IODRESSforfeesandCharges: OWNER ❑ FACILITY/BUSINESS BILLING AND COMPLIANCE ACKNOWLEDGMENT: [,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 andfor HOURLY CHARGES associated With this Operation will be billed t0 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 ReAulations. i APPLICANT'S NAME: SN Ent CpPJN�LI,y SIGNATURE: n / Tn1E. Please Print DATE I .20 `��7 z3GlP �Y1 N C IZ ` I� (PHOTOCOPY R$UIRED Approved By Dao Accouminp Olson Processing Completed By oda 5/'1✓/l7 A PRGaRAM(EHD 48-02-084 Pink)or WATER SYSTEM(EHD 484Y2-009)Torn must be completed for each EHD regulated operation at this LOCATION except UST Program(Use SWRCB forma) EHD 48-02-035 Masterfile Record-Green 11/27ID7