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Kenneth W. Blakemore LeSM`° °" <br /> tt leu I1V RemNer-CauaY Ckh <br /> )4'• � <br /> San <br /> "'�•.OG Joaquin County Debra <br /> a WilWilson <br /> 2: Z r son <br /> R=v -counryf:lak <br /> Assessor — Recorder — County Clerk Debra Leooardini <br /> :• akf.fv.w.a.o <br /> • C`q, `'p 44 N.San Joaquin Saw Suite 210,Stockton,CA 95202-3273 <br /> �iFVRP Assessor (209)468-2630 FAX(209)468-0422 <br /> Recorder-Clerk (209)46&3939 <br /> � <br /> + STATEMENT OF�}CHANGE FORM <br /> Owner Name f11Pc' EatC72A \ Z( -G 1 �2r� 1 ) L1JC <br /> APN/AAN 1'7 q-- 177 I - 13 _Telephone`No. 911, -L-11 —I&ILILL <br /> Business Location a-}ZL3 Q'rwVp (l j . a QS.2-� <br /> Please complete the appropriate section,sign and return the completed form as soon as possible. <br /> WasSOLD BUSINESS Date Sold <br /> Complete NEW OWNER INFORMATION below. <br /> ❑ MOVED BUSINESS(In or Out of County) Date Moved <br /> Address of New Location <br /> If you Moved within this county,did you receive a Property Statement for this new location? <br /> ❑ YES 4 NO If yes,account/parcel no.from that statement <br /> ❑ PERMANENTLY CLOSED BUSINESS Date Closed <br /> Disposition of assets: ❑ Sold(Complete NEW OWNER INFO.below) ❑Abandoned ❑Other <br /> ❑Never Opened Business <br /> If Other,explain <br /> If you ceased doing business as a result of a foreclosure,did the business continue to operate at <br /> this location under new ownership? ❑ Yes(Complete NEW OWNER INFO.below) ❑ No <br /> NEW OWNER INFORMATION <br /> Name <br /> Address j b(Z S o 6n/A Ce,lk Db %ye znr l 0 cf!7 aj a U-4- cj 5670 <br /> Phone No. t <br /> I declare under? natty of perjury that the above statement is true and correct. <br /> -' 3? -rRlilz Z 3t�0 <br /> Si/grWhre of Owner,Officer or Authorized Agent Phone No. Date <br /> ffite: California Revenue and taxation code Section 461,False Statement: <br /> Every person who willfully states anything which he knows to be false in any oral or written statement,not under with,required or authorized <br /> to be made as the basis of imposing any tax,is guilty of a misdemeanor and upon conviction thereof may be punished by imprisonment in the <br /> countyjail for a period not exceeding six months or by a fine. <br /> If you have any questions regarding this form,please call(209)468-2640 or fax(209)468-9351. <br />