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Dec 17 2013 2: 37PM Kell�j 's Express Car Wash 20 -5885 p. 2 <br /> cft ioREWEIVED <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM DEC 17 2013 <br /> _ 1 I ' i,71 L <br /> S)14WD SEC70W FoR EHD Um OmY <br /> P <br /> OWNER FILE <br /> CCAIPLETETwFCILOWJNGBUSINEss OWNER QYFORAWTAw- Crr v,OWNER Cu REHZ Y0,VME WWOH <br /> nrx <br /> BUSINESSPHryOO'�''NE: <br /> OWNER's NAME �I t A+ el � Lan L+T' LrIG ��1N <br /> BUSINESS NAM(HaR6rw,tf& OWININraa) 800 Bea arTee ID• <br /> Ke-11 r ss s in LL-Ci 2tp - L4 L4Q <br /> OWNER'S HOMeADDRESs <br /> Cm s I zip 5 2-1 CL <br /> OWNER'SMIAIURGADDREss (a d#%rwmfR Or r`*Addroae) AtletllnerOraN <br /> YVUk <br /> MAIUNc ADDRESS Cm STATE <br /> TrPEorowlm+sHt*. <br /> OmPORATION❑ INDIVIDUAL[] PARINEMH ❑ Locx AOENOV❑ COUNTYAMNCY❑ STATE AOMOY❑ FEDAaENOV❑ <br /> FACILITY FILE 2 <br /> �''F FIT�ID9k 00F,0 I7r.9e7 =t. r,. <br /> CoAwL TE THEFoLLoWAYGBU61 N I — T I <br /> N <br /> as this a NEW Business LOCAnON Or YEa/1CLE not previously regulated by the ENVIRCNt@rrAL HEALTH DEPARTMENT? YES NO ❑ <br /> Is this an E(IanNu Business LooATIoN but a NEW TYPE of regulated Business? Ym ❑ No <br /> BuMNEss/FACiLm (The VAN be the sPW <br /> An) <br /> HEALTH PM <br /> k-51 I <br /> FACKM ADDRESS Of FA0ffriA ffVftNAe Fcao V1DeZsuaa se Coatme wA&DaEesl BUSWESSPHONE <br /> 112 5" ve- <br /> City(t,FAc,CCurvr aM�o-t,at�L�EF000t/mmor Poon VERLYE uad theCOMWVL*ff GnI STATE� Zip —1 21 <br /> V�t..:e'�. CA <br /> .I 3 rot ! 'r a '+ I $ l�l� !�1 ("4c, ''rd`�' r M� 11 <br /> y <br /> 5 <br /> �MMLINOADORM 11brlb1/d?Pennll(M D/fFFR�AR&am Faca4s•Addr&ss1 ASerNlan&rCarad <br /> (yn ire. <br /> Mau iTY srA7 ,n Z'P GtS Zl <br /> ea r. <br /> . RTTI <br /> . niefll,,l <br /> gQCp?/ AIDGMEMfior fees and charp}a: OWNER , FACILITYIBU81N <br /> BILLING AND COMPLUNCE ACKNOWLEDGMEM: I,this I lndemlgned Applicant,CeRNy that l ar the Owner.Opendw,,or Aufh gardofthk Business,ands <br /> acknowledge that all Parer FEES,PENALTIES,E J DRcmws,N CHArrGEs andlor Hou,,LY CNARGEs associated with this operation wM be billed to the at the <br /> address identified above as the ACCWmTADDRES670r this site. 1 also!amity that all Infonnallon provided on this application is true end correct;and that 81I <br /> regulated actiVltie3 will be peHormed In accordant&with all applicable SAN JOAOUIN CGUMY Ordinance Codes andlor Standards and STATE andfor FEDERAL <br /> Laws and Ramlatlons. <br /> APPLICANT'S NAs�: �AW Q BNiNATURE: <br /> 2 <br /> TIRE: OAS DRI <br /> ROTOCs PY uIR� <br /> �. <br /> R� • .- t ti{ ST,. �'dJ,�+`T ry fl a ..F �rl� "'4 M .� .: n7mwbt.dtty . .;_. I ( :', r '. 9 W A. <br /> 0.nIL• 5..,,,, I .W�,.t JX ..e l ,. .,.! ' ..:1,.5 rr . . <br /> A PROGRAM(CAD 45-02-W Pink)or WATER SYSTEM(EHD 45-02-003)form rrAW be completed for Mitch Ell regulated operation at this LOCATION <br /> eildept UST Program(Use SWRCB forme) <br /> Maelerale Recortl•Green <br /> Ell 48-02.035 <br /> tussles <br />