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SAN ,.,JDAQUIN Environmental Health Department <br /> CnUNTY <br /> BUSINESS INFORMATION <br /> LEGAL BUSINESS NAME. <br /> Cultiva LLC <br /> BUSINESS PHYSICAL ADDRESS CITY STATE: ZIP CODE <br /> 12811 Dro a Road, Building D ESCALON CA 95320 <br /> BUSINESS MAILING ADDRESS: CITY: STATE. ZIP CODE: <br /> 411 Lewis RD SPC 329 San Jose CA 95111 <br /> BUSINESS LOCATION PHONE I BUSINESS LOCATION EMAIL ADDRESS ASSESSOR'S PARCEL NUMBER PLANNING APPLICATION NUMBER. <br /> 408-668-5158 ILeondt@gmaii.com 207190410000 Use permit in process <br /> LAST NAME SOLE PROPRIETORSHIP ONLY FIRST NAME SOLE PROPRIETORSHIP ONLY <br /> BUSINESS TITLE SOLE PROPRIETORSHIP ONLY <br /> BUSINESS MAILING ADDRESS CITY STATE I ZIP CODE <br /> PHONE NUMBER I EMAIL ADDRESS. <br /> 408-668-5158 ILeondt@gmail.com <br /> BUSINESS ENTITY STRUCTURE: <br /> ❑ Corporation X Limited Liability Company ❑ Limited Liability Partnership ❑ Limited Partnership <br /> ❑ General Partnership ❑ Sole Proprietorship ❑ Joint Venture ❑ Trust <br /> ❑ Sovereign Entity ❑ Other(specify): <br /> Is this applicant business entity a foreign ❑ Yes—Attach Foreign Corporation's Certificate of qualification issued by the California <br /> corporation? KNO Secretary of State per Corporations Code,Section 2105. <br /> Is this applicant business entity a cannabis <br /> cooperative association per Business and No El —Attach List of members of the cannabis cooperative association. <br /> Professions Code,Chapter 22? Name of Association: <br /> DESIGNATED RESPONSIBLE PARTY <br /> DESIGNATED RESPONSIBLE PARTY LAST NAME I RESPONSIBLE PARTY FIRST NAME: RESPONSIBLE PARTY BUSINESS TITLE <br /> Nguyen Leon Owner <br /> RESPONSIBLE PARTY MAILING ADDRESS. CITY: STATE. ZIP CODE. <br /> 411 Lewis Road SP 329 San Jose CA 95111 <br /> RESPONSIBLE PARTY RELATIONSHIP TO BUSINESS PHONE NUMBER I EMAIL ADDRESS <br /> Owner 408-668-5158 ILeondt@gmaii.com <br /> CONTACT#1 <br /> CONTACT LAST NAME CONTACT FIRST NAME. CONTACT BUSINESS TITLE. <br /> Norman Hau An lowner <br /> CONTACT MAILING ADDRESS CITY I STATE ZIP CODE <br /> 686 Ann PL Milpitas I CA 195035 <br /> CONTACT RELATIONSHIP TO BUSINESS: PHONE NUMBER I EMAIL ADDRESS. <br /> Partner/owner 408-757-9010 <br /> CONTACT#2 <br /> CONTACT LAST NAME I CONTACT FIRST NAME. CONTACT BUSINESS TITLE: <br /> CONTACT MAILING ADDRESS: C ITY I STATE. ZIP CODE. <br /> CONTACT RELATIONSHIP TO BUSINESS PHONE NUMBER I EMAIL ADDRESS: <br /> 12/11/19 2 of 2 <br />