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02/06/2012 16:25 2094640138 ENVIRONMENTAL HEALTH PAGE 01/02 <br /> Feb. 6. 2012 3:451'N ,lencia Country Club No, 1656 P. 1��/1�'1� <br /> 0aluw zrilz 10:X0 109 aau ENVIRONMENTAL HE r" Qlv�2 V o <br /> FEB - g 2012 <br /> SA'VJSan ME <br /> Joaquin County <br /> kt o OFfRG NCYSE VICES <br /> Environmental Health Eippar -mena <br /> 800 E. Mein St, FAX#: m (209)484.0138 e <br /> Stockton, CA 95202 O (209) 468-8392 <br /> Phone: (209)468-3420 0 (209) 468-3433 <br /> LFAXDate: 216112 Time; 10.25 am <br /> # of Pages (including this sheet): M <br /> Gress EIM FAX#_ 1(6671 264.5853 <br /> Of: � MiCke Grove Golf Course <br /> Violet Davis _ Voice Phone#: (209195 -7895 <br /> Re: Form 5021 —Change of Owner <br /> O Urgent O For Review O Please Reply O Please Recycle <br /> comments: <br /> Please complete new owner information on the right side of attached <br /> form, include Tax ID#and return to above fax number or mail to above <br /> ddress. Thank you. <br /> STATEMENT of coNrl Wlnb bcetmlle l3 e1M OfierdVed ill0oenfrlendal WlNmve for Mw el Ap MOW" <br /> 1hW tMi1Wereneel. VlheMdW oISMSl 2"Wpq cine• Sec polroAllebdNlWrlro lee Irawy ro6odlx ob <br /> e mNNed nn en e•e n• ohne:relem WeW mM A r dmlh In/rter Nlelmlead Vary <br /> ne Ve Dy IM! OM eTrym r 1 pn Ower McMlnVNNln VroO NnNleq rode 6t Iee•eN IeRe 9 NIM 6AlW Pa�n119eNlte. We"11 <br /> nITWAlVeurte•L51n nMV,dnr Vi MdreNMnr lll�mw••g•Is ul. TneHI YlY. <br /> EMD 4eO1.012 FAX COVER SHEET <br /> REVISED&14-D2 <br />