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San Joirl County Environmental Health �► � � /I� <br /> � ORM <br /> DATEMASTER FILE RECORD INFORMATION "MFR" <br /> 4-1-04 1 6 � Qp� <br /> gxADEOAe CAC Pon FNA 19F OM <br /> xv OWNER ID# CASE ENVIR UNIT IV <br /> OWNER FILE MIT/SERVICES <br /> COMPLETE THEFOLLOWINGPROPERTY OWNER INFORMATION; CHECKIF OWNER CueRennrONFITE WRH END <br /> PROPERTY OWNER NAME STONE BROS. 6 ASSOC TE PHONE Y09-478-1791 <br /> First I MI Last <br /> BusINFSs NAME STONE BROS. S ASSOCIATES Sot SEC/TAx ID# <br /> Owner Home Address pgnr <br /> 1024 W. ROBINHOOD DR. <br /> city STOCKTON STAnCA vP 95207 <br /> Owner Mailing Address <br /> 1024 W. ROBINHOOD DR. <br /> Mailing Address City SAME State Zip <br /> TVOG TIC awxC....D ,y <br /> CORPORATION❑ INDMDUAL❑ PARTNERSHIP L'7 FED AGENCY❑ DTHER❑ <br /> FACILITY FILE <br /> F^cx R ID# CRDs REF ID# ACCOUNT ID# IW# <br /> COMPLETE THEFOLLOWrNG BUSINESS I FACILITY ISITIF rNFORMATrolli. <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No IN <br /> Is this an EIOSTING Business LOCATION but a NEW TYPE of regulated Business? YES No ❑ <br /> BUSINESS/FACRJrY/SITENAME SHERWOOD MALL SHOPPING CENTERIROBINHOOD PLAZA^ <br /> SITE ADDRESS <br /> 5400 PACIFIC AVE. 6 5606 PACIFIC AVE. Sum# BUSRIfAsp48pRE 1791 <br /> Cm <br /> STOCRTON STATE CA zw 95207 <br /> SOARDOFSUPERWSORDISrWR LOfATION CODE KEYl KEY2 <br /> Mailing Address/FDIFFERENT/rom fan/ityAddress Attention:of Care Of(optional) <br /> 1024 W. ROBINHOOD DR. <br /> Mailing Address City STATE Zip <br /> CA 95207 <br /> SIC CODE APN# COMMEYfr: <br /> THIRD PARTY BILLING INFO: COmpleteif Billing Party is differentfrom Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Attention:orCare Of (optional) <br /> Mailing Address PHONE <br /> CRY STATE ZIP <br /> Accaw Tenn M for fees and charges <br /> OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILI 1NC.AND COMPt I ANCF ACKNOW rnrxwrNT: 1,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and 1 acknowledge that all PERMIT FEES, <br /> PENALTIES,ENFORCEMENT CHARGES and/or HOURLYCHARGES associated with this operation will be billed to me at the address identified above as the ACCOLYT ADLER for this site. 1 also certify that all <br /> information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above facility/site address,1 hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> APPLICANT NAME PLEASE PROIT <br /> SIGNATURE <br /> TITLE <br /> DRIVER'S LICENSE# <br /> (PHOTOCOPY REQUIRED) <br /> Approved BY Date Accounting Office Processing Completed By Date <br /> 29-02-002 Apn125,2003 <br />