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San Joaquin County Environmental Health Department <br /> DATE 11/16/07 GREEN FORM <br /> MASTER FILE RECORD INFORMATION "MFR" <br /> suaoA�.. xQyyeaxa OWNER IOM CASE# UNIT IV <br /> OWNER FILE <br /> COMPL,Ew rwFOLLOW/NG PROPERTY OWN ER iNfORMAwiw CHIECK IF OWNER CUR£EMa YO vFae wnnEHD <br /> PROPERTY OWNER Surrey,Ltd. PHONE 209-478-1791 <br /> NAME <br /> F s( MI Mti <br /> BusmEss NAME ROBINHOOD PLAZA SHOPPING CENTER Soo SecITAXIDM TAXIO <br /> Owner Home Addreas 1024W.Robinhood Drive,Ste.#1 DRIVER'S LICENSE# <br /> city Stockton STATE CA ZIP 95207 <br /> Owner Melling Addreee 1024 W.Robinhood Drive,Ste.#1 <br /> Mailing Address City Stockton State CA Zip 95207 <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIPXXQ FED AGENCY OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID# CROSS REF ID It ACCouNT ID M INV# <br /> ComPLETE rHE FOLLOW/NG B USIN ESS I FACT LITY/S ITE fNFORMA riom <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No ❑ <br /> Is this an EXISTING Business LOCATION but a NeWTYPE of regulated Business? YES ❑ NO ❑ <br /> BUSINESSIFACILITY/SME NAME ROBINHOOD PLAZA SHOPPING CENTER <br /> Sm ADDRESS 5756 PACIFIC AVENUE SUITE# BUSINESS PHONE 479-1791 <br /> CITY STOCKTON STATE CA ZIP 95207 <br /> IIBOAROOPSUPERvisoaDiSTRICT I I LOCATION CODE I I KEY1 I I KEY2 I II <br /> Meiling Address ND/FFEREsYrrromfincl yAdDinew 1024W.Robinhood Drive. Attention:or Care Of(eat(mel) <br /> Mailing Address City Stockton '�.J� STATE CA ZIP 95207 <br /> SIC CODE - APN 9 I Q Rq� ' Tv <br /> :Z IID COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Attention:orCare Of (opf eYlal <br /> Mailing Address PHONE <br /> CITY STATE ZIP <br /> ACC01/1yJ_9DO85£8 for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND CONPLIANCF.ACKXOyLEDCAIENT: 1,the undersigned Applicant,certify that 1 am the O,AmT,Operator,or 11X1/tamed Agent of this Business,and 1 aclmmdedge that all PE&tur FE£5, <br /> ARNALTl£S,EXFoRmitew f71URacs and/or RRLRLY0mRCES mu oclated Mich this operation MR be billed to meat the address identified above Af the ACCDUMADOR£SS for this site. 1 also certify that aB <br /> information provided on this application Is true and correct;and that all regulated activities HIS be performed in accordance with all applicable SAN JOAQUIN Cot, Ordinance Codes ondfor <br /> Standards and STATE andAr FEDERAL Laes and Regulations. As the undersigned owner,operator,or Agent of the property located at the above facillty(site address,1 hereby authorize the release of <br /> any And all resWG and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONbIENTAL HEALTH DEPARTMENT a<soon as It is available and at the same time It is <br /> provided to me or my representative. <br /> PLEASE PRINT /f <br /> APPLICANT NAME JAYALLEN SIGNATURE <br /> AAS DRIVER'S LICENSE# <br /> TITLE <br /> t_ )� (PHOTOCOPY REQUIRED) <br /> Approved By Dete Accounting Once Processing Completed By Out <br />