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San Jr -ruin County Environmental Health "apartment <br /> GREEN FORM <br /> DATE 9/30/10 MASTER FILE RECORD INFORMATION "MFR" <br /> SHADED AREAS FOR EHD USE ONLY OWNER ID# Zq H CASE# UNIT IV <br /> �lfJbD b <br /> OWNER FILE <br /> COMPLETE THE FOLLOWING PROPERTY OWNER INFORMATION: CHECK IF OWNER CURRENnrONFILE WITH EHD❑ <br /> PROPERTY OWNER NAME PHONE 310-277-0456 <br /> Blake Megdal <br /> First MI Last <br /> BUSINESS NAME ELLIOT MEGDAL&Assoc. TAx ID# <br /> Owner Home Address 1875 Century Park East,#1840 DRIVER'S LICENSE III <br /> city Los Angeles STATE CA ZIP 91x167 <br /> Owner Mailing Address (SAME) <br /> Mailing Address City state Zip <br /> TYPE OF OWNERSHIP <br /> CORPORATION® INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FAaLrTY ID# H"D IlBCROSS REF ID# �Or�M ID �O� INV# <br /> d JCOMPLETE THE FOLLOWING BUSINESS/FACILITY/SITE INFORMATION: <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 NEw TYPE of regulated Business? YES ❑ No ❑ <br /> BU5INEs5IFAOLTTYISrrENAME PROPOSED Fresh&Easy Neighborhood Market <br /> SITE ADDRESS 6632 PACIFIC AVE. SUITE# BUSINESS PHONE 310-341-15S5 <br /> CITY STOCKTON STATE CA ZIP 95027 <br /> BOARD OF SUPERVLSOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> Mailing Address if DIFFERENT from Facility Address 2120 Park Place, Suite 200 Attention:or Care Of(optional) Randy Jones <br /> Mailing Address City EI Segundo STATE CA ZIP 90245 <br /> SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME SALEM ENGINEERING GROUP Attention:or Care Of(optional) Bruce Myers <br /> Mailing Address 4055 W.Shaw Ave.,#110 PHONE 559-271-9700 <br /> CITY FRESNO STATE CA ZIP 93722 <br /> IACOLINTADDREss forfees and charges OWNER FACILITYIBUSINESS HIRD PARTY BILLING <br /> BIIAANG.AND COMPLIANCE ACKNOYN'LEDGAIEN1: I,the undersigned Applicant,certify that 1 am the Owner,Operator.or Authorized Agent of this Business,and 1 acknowledge that all PERMIT FEES, <br /> PEn:4LT/ES,En'FORC£nfEA'TCK4RGES and/or HouRLYC/L4RGES associated with this operation will be billed tome at the address identified above as the ACCO(m'TADDRE.SS 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 properh located at the above facility/site address,1 hereby authorLw 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 /> PLEASE PRIM <br /> APPLICANT NAME BRUCE MYERS SIGNATURE L n^n �/ <br /> TITLE /i'V t/ <br /> Senior Geologist <br /> Approved By Date Accounting Office Processing Completed By Date l L ((� <br /> 71)_001 A'617 1001 <br />