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I <br /> RECEIVED 12/11f 23:46 <br /> 12!12(2012 10:51 209463 <br /> SJC EHD MIT 3 1W PAGE 01/01 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> 7 I 7q <br /> t <br /> �M1 <br /> SHR#DSECYpNSEOR EEIbf]SE ONLY <br /> OWNER FILE <br /> CQMFLETETN£FoLLOW/NGBU$INES$OWNER 1NFORAW70M' GKc/r+r<bWNER CUAaenrx rantace WirrtEHD❑ <br /> PHDNE: <br /> OWNER'sNAME <br /> EUSOIM 4NAMEIN 0i ner <br /> OWNER'S HOME ADDRESS <br /> CITSTATE LP <br /> Y <br /> OwNSR'SMAUNGADM"(HdiAererrrNdnOwn+r:Adwaw) Amadenargamof <br /> I �_3 F 1- vd. STATE <br /> MALINGADDREss Crry a ti,.n zw 7—1 <br /> 'MEOFOWNN�9f11Y: r-t <br /> CORPORATION❑ INONIGUAL PmiNERs ,P❑ LOCALAGE11 COUNvAuEN"n $TATEAcFutg'r❑ FDD AO"mo 2nj! <br /> �148Da In FACILITY FILE <br /> I trllYt w' �, d oil 4J <br /> COMPLETE THEFOLLGWWG BUSINESS FACILITY JNFORMA77M', <br /> IS fWSH Nf:W Buektasa LOCAYN)N arY9(fblE nOtpfaVlOUaly repulatsdhy gra FxvtRtNlYettrAl MIEAI.TN DaPA)MNeNY7 Yes,Id1 NG ❑ <br /> Is this an EXtaT a Buaino"LOCATION 164413 New TrPe of regulated 9uolnasa? Yss [] No <br /> BUSING �AC�ILR`l NAME wai eaves Bia+aasNAra'«+tNa Ht;A1.TtIPERatrf) <br /> T"ro n jotPr�>•�-t BU/$p�+}Ess PHDNEt�. <br /> CDv d a FomltarorF000y'6iMlsuaadfacnraaaasrndrA 2JP9-50)5 <br /> Z. �2. ` jT -���„JCY <br /> IdAIf4x,Hae th Parmilfwwrre;rrmTh"R r +Naro.,ol� <br /> 11 t-1`Z,�a r1YY� /t V <br /> STATE CA Zw L4 <br /> 1. <br /> ACGf MAAMULI(Trte"and ChargeS: OWNER ❑ FACIL)TY/BUSINESS <br /> BILLING AND COMPLIANCE ACKNM. EDOMENT. [,the undersigned Apptkarrt,certify that i am the Owner,Operator,or Authorized Agent of this Business,and s <br /> ac"awledge that 29 PER T Fck.pENALmr ENFORCv&WT CHARGES andror Howa.Y CHARGES asax4wted with this operation will be billed to me at the <br /> address ldemlfwd at70vd a9 tfiCACCWMAO!_�RP,,,afM thi9 aitE. Iana,4arfity that all lnforinatiOn pmAded on this appbmbon is true and t vct;and that all <br /> regulated activities will be parfomlad in aeoerdance with ail appliCable SAN JOAQUIN COJmr'7 Ordinance Codes andbr Stand rds and STATE andfor FEDERAL <br /> Laws and Reaulations. J <br /> APPUCANT's NAME: 0 viver,- <br /> P ...�GYIY? )'1 SIGNATURE: <br /> /��, !assn pled IST ` �o'^- DRIVER'S UC 'NSaffi ��� <br /> TnE: V �'��?.��PDATEFIL ry- I pHoracorvR uteo <br /> '' . .y <br /> A PROGRAM(EHD 49-02.094 Pink)or WAwR SysTem{EHO 48,02-003)fon,tpA!g be oompleted for each END reguialed operation at this N <br /> soccePt UST Program(Use SWRCBforma) Masterfito Record-Grain <br /> EH048-02-035 <br /> 11Y27107 <br />