Laserfiche WebLink
L <br /> San Joaquin County Environmental Health Department <br /> DATE 7/709 MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> SmsEA¢erS s an FND ose ax,v OWNER ID# l CASE# UNLIT IV <br /> OWNER PILE <br /> COMPLETE THEFOLLOWING PROPERTY OWNER INFORMATION.' CHECN/F OWNER CURRENrLYONFILEWIRVEHD <br /> PROPERTYOWHER SUITCy LLC / PHONE 209-478-1791 <br /> NAME / UEL-L.. T ALt. N <br /> first ab last <br /> BUSINESSNAME ROSIN140ODPLAZASHOPPINGC6N'fER /. See SEc I Tra 10# TAX IE <br /> Owner Home Address �{/ �Q8(/Jr(66,� QC.,Spar Z62 DRIVER'S LICENSE# <br /> city Stockton ye SrnrE CA ZIP 95207 <br /> Owner Mantra AEErnaa /036 :Pr<SQfNKea9 (J4 f Surl& zo'L <br /> Mailing Address City Stockton State CA zip 95207 <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIPXX❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITY to CROSS REF ID# AOCOUNTID# INV# <br /> COMPLETE THE FOL L0WVVG BUSINESS I FACILITY I SITE INFORMAT/ON.- <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 ofregulated Business? YES El NO ❑ <br /> BUSINESSIFACILITYISITE NAME ROBINHOOD PLAZA SHOPPING CBfa9'ER <br /> SITEADDRESS 5756 PACIFIC AVENUE SUITE BUSINESS PHONE47$-1791 <br /> CITY STOCKTON STATE CA ZIP 95207 <br /> IIBOARD OF SUPERVISOR DISTRICT I LOCATION CODE I I KEYI I NEr2 I II <br /> Mailing Address 1fc1FFERENrJHm Facl/RyAdYmaS, Attention:or Care Of(optional) <br /> /b 36 12o,9iy�d L>Q� .SGS 202 <br /> Mailing Address City Stockton STATE CA ZIP 95207 <br /> SIC CODE < i APN# COMMENT: - <br /> THIRD PARTY BILLING INFO: Completed Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Attention:orGare Of (optional) <br /> Mailing Address PHONE <br /> CITY STATE ZIP <br /> ACCO_U RRWM forfee$and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> Bn I li'G Sae COosPLIANCE ACK.NOwt,EDOBIENr: 1,the undersignnl.Applicant,certify that 1 an the£hviser,Operator,or Awhoriced A.em of this Business,and 1 aclelmsledge that all PERwr FEts, <br /> PENALTILE,Ewroacs�tEAT CIUROE5 and/or HOL'RLTCIUREES associated mith rill be billed to meat the address identified abase as thadrenuVr,InnR£ss farlhls He. Ialso cartiry that all <br /> inrormalion provided on Ibis ippllcation Is erne and correct; and that all regulated ectlAbe;nail be perfnnued is aceo¢ianre Mill all applicable S:w JOAQW,u Cotorn'Ordinance Codc and/or <br /> Standards and STATE and/or FEDER%L LSRS and Rogulatiom. els the undersigned miner,operator,or agent of the property NRaled at the abnve facillNlsite address,1 herelYY vothariz&the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It$available and at the tame small Is <br /> provided to me or my representative, <br /> PLEASE PRINT I ,t <br /> APPLICANT NAME JAY ALLEN SIGNATURE <br /> TITLE , DRIVER'SUCENSE# <br /> fPNOTOCOPYREQUIREO) <br /> Approved By DDIe Accounting Office Processing Completed By <br />