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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> SNADEDSECTIDNS FOR EHD USEONLY OWNER I D# CASE# <br /> OWNER FILE <br /> COMPLETE THEFOLLOw/NGBUSI NESS OWNER INFORM47701W CHECK IF OWNER CURRENrLYOAfRLEwfrHEHDO <br /> — 77777 <br /> BUSINESS Jo}uz Firsf g Phillips PHONE:(2U9) 944-0909 <br /> OWNER's NAME <br /> MI Las! <br /> BUSINESS NAME(N dilferentfromowner Name) Soo See OrTax ID# <br /> Idealease <br /> OWNER'S HOME ADDRESS 1133 Bristol Avenue p-r� <br /> CITY Stockton STAG ZIp 95206 <br /> OWNER'S MAILING ADDRESS(if diHwent fromOWnees Address) Atlendon wCsre of <br /> MAUNGADDRESSCITY STATE ZIP <br /> TYPEOFOWNERSHIP: <br /> CORPORATION❑ INOMDUAL© PARTNERSHIP El LOCALAGENOY❑ OOUWYAGENCY❑ STATE AGENCY 11 FEOAGERCY❑ OTHER[-] <br /> FACILITY FILE <br /> FACIUTYID#: CO-OYYNER ID#: ACCOUNT ID#: <br /> COMPLETETHEFOLLOW/NG BUSINESS FACILITY/NFORMAT/ON.' <br /> Is this a NEW Business LOCATION Or VEHICLE notprevlously regulated by the ENVIRONMENTALHE :TH DEPARTMENT? YES ❑ No KI <br /> Is this an Em"NG Business LOCATION but a NEwTYPE of regulated Business? YES ❑ No <br /> BUSINESSIFACILIrY NAME(This will be the Buv iS3SAf wEonthe HEALTH PERMIT) <br /> Idealease <br /> FACILITY ADDRESS(irFAAYUmis a MOaKEF000 UWirorF000 I/s I=Euse the CONNss RY ADDREssl BUSINESSPHONE <br /> 1137 South Stockton Street t209) 944-0909 <br /> SuRe# <br /> CITY(It FAcums a MoaneF000 UworF000 VEHIcIeuse theCommmmY Cwl STATE ZIP <br /> Stockton CA 95206 <br /> BOARD OFSUPERVISOR DISTRICT LOCATIO ICODE KEY1 KEV2 <br /> MAWNG ADDRESS forHealdr Permit(N DIFFERENTrrem FacliltyAddress) AMentlon orCere Of <br /> Mark Buller <br /> MAILING ADDRESS CITY STATE ZIP <br /> SIC?ADE: APNN: Coarmrt: <br /> ACCOUNTAODRESSforfees and charges: OWNER x❑ FACILITYIBUSINESS ❑ <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Appliwnq certify that I am the Owner,Operator,or Authorized Agent of this Business,and I <br /> acknovAedge that all PERMIT FEES,PENALTIES,ENFORCEMENT CHARGES andlor HOURLY CHARGES associated With this Operation Will be billed t0 me at the <br /> 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 <br /> regulated activities will be performed in accordance With all applicable SAN JOAQUIN COUNW Ordinance Codes andlor Standards and STATE and/or FEDERAL <br /> Laws and Regulations. ,t <br /> APPLICANT'S NAME: Mark Huller SIGNATURE: <br /> Please Print DRIVER'S LIDENSE# <br /> TITLE: Manager / Idealease DATE 12-10-14 PHOTOCOPY REDUIRED <br /> Approved ev Data Accounting Office Processing Completed By Date <br /> A PROGRAM(EHD 48-02.034 Pink)Or WATER SYSTEM(EHD 46-02-009)form TIL be completed for each EHD regulated operation at this LOCATION <br /> except UST Program(Use SWRCB forms) <br /> EHD 48-02-035 Masterfile Record-Green <br /> 11127107 <br />