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San Joaquin County Environmental Health Department <br /> DATE 11/16/07 f MASTER FA-eILE RECORD INFORMATION "MFR" GREEN FORM <br /> 7 O I ' <br /> 9wwnanru ran EHDme OVL OWNER ED# CASE It UNIT IV <br /> OWNER FILE <br /> COMPLETE TNEFOLLOW/NG PROPERTY OWNER INFORMATION.' CHECKIF OWNER CVRREWnY0WRLEwnNEHD <br /> PROPERTY OWNER Surrey,Ltd. PHONE 209-478-1791 <br /> NAME <br /> Fvsl M/ last <br /> BUSINEss NAME ROBINHOOD PLAZA SHOPPING CENTER Soc SEcITAx ID# TAXID <br /> Owner Home Address 1024 W.Robinhood Drive,Ste.#1 DAwER'S LICENSE# <br /> city Stockton STATE CA 21P 95207 <br /> Owner M.nine Adds.. 1024 W.Robinhood Drive,Ste. #I <br /> Mailing Address City Stockton state CA Zip 95207 <br /> CORPORATION❑ INOWIDUAL❑ PARTNERSHIPXX❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITY to# CROSS REP ID# ACCOUNTED V INV# <br /> COMPLETE TNEFOLLowmi; BUSINESS/FACILITY/SITE INFORMATION.' <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No ❑ <br /> Isthisan ExISTING Business LOCATION but a NEwTYPE ofregulated Business? YES ❑ NO ❑ <br /> BUSINES91FAcILITY/SITE NAME ROBINHOOD PLAZA SHOPPING CENTER <br /> SITEADDRESS 5756 PACIFIC AVENUE SUITE# BUSINESS PHONE 478-1791 <br /> CM STOCKTON STATE CA ZIP 95207 <br /> BOARD OF SUPERVISOR DISTRICT I LOCATIONCODE I I KRY ` I I KEYS I II <br /> Mailing Address YDIFFERFJJTbom,FRcl/fly Address 1024 W. Robinhood Drive. Attention:OF Care Of(Oadwal) <br /> Mailing Address City Stockton STATE CA ZIP 95207 <br /> SIC CODE 711 APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete If Billing Party is differentfrom Property Owner or Facility Operator identified above, <br /> BUSINESS NAME Attention:orCare Of (opllnne/) <br /> Mailing Address PHONE <br /> CITY STATE ZIP <br /> AQQoUNjAD.DEES.B for fees and charges OWNER FACILITYIBUSINESS THIRD PARTY BILLING <br /> BU.I.sn'G AND ConIPLIANCE ACK,Nowl.EnGTIE.vT: 1,the undersigned Applicant,certify that 1 am the Owner,operator,or.brthuriced Agent of this Business,and 1 aelalowledge that all PERH/TFEEs, <br /> PmLnzs,Ew oseevERrCauRees and/or ffousr.yCtunas avocinted with Ihle operation will be billed to meat the address Identified above a,the Acc wwAOnsers for this site. i also certify that all <br /> Information provided an this application Is true and correct and that.11 regulated mired.will be performed in accordance with all applicable SAN JOAQULu COW, Ordinance Coda andtor <br /> Standards and STAT[and/or FEDIAL ,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 restats and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It N available and at the same time it is <br /> provided to me or my representative. <br /> PLEASE PRINT A <br /> APPLICANT NAME JAY ALLEN SIGNATURE z <br /> TITLE Y/ DRIVER'S LICENSE <br /> (PHOT000PYREQU1REO1 <br /> Approved By Date Accounting Office Proceasing Compl-we Date <br />