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- - JS. <br /> Kenneth W. Blakemore Les Flemmer <br /> gSIN IN, Assiwd)4• C--.1 <br /> - _�Q••CA` RemNer-Co.1 rcy Ckrk <br /> 2 . Z San Joaquin County Debra Wilson <br /> 00:: . akfofstawray <br /> Assessor — Recorder — County Clerk Renner_Coany Ckh <br /> Debra l.eonardini <br /> �•f(t F b��)p 44 N.San Joaquin Street Suite 230,Stockton.CA 95202-3273 C,efof vamnwo <br /> Assessor (209)468-2630 FAX(209)4694M22 <br /> Rec'order—Clerk (209)468-3939 <br /> STATEMENT OF CHANGE FORM <br /> Owner Name �I)Pc' ?.,'7� c� 4Z(�� y np -� I nk )C <br /> APN/AAN 7 q=�7 - Telephone No. 91 L2 -11- 1 -! gQLf- _ <br /> Business Location tjZt3 (? L r1c D'riv'e, � ► i �f} (� 5�2ir— <br /> Please complete the appropriate section,sign and return the completed form as soon as possible. <br /> 2/SOLD 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 C)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 i-'( �A { C— <br /> Address ih(Z5o ret! Cep-le.r D�tv2 1, C'.L5 ('A.la ,U-1- cl5670 <br /> Phone No. S <br /> I declare under p runty of perjury that the above statement is true and correct. <br /> �a -631' t/ 1 L TI/Q <br /> Sig ure of Owner,Officer or Authorized Agent Phone No. Date <br /> [e: Caut-7.Revenue and taxation code Section 461,False Statement <br /> Every person who wi0fully states an <br /> which It knows m be false in any oral or written statement,not under oath,required or authorized <br /> /m <br /> be made as the basis et imposing any tax,is guilty of a misdemeanor and upon conviction thereof may be punished by imprisonment in[he <br /> county jail fora 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 />