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San Joaquin County Environmental Health Department DATE MASTER FILE RECORD INFORMATION "MFR" GREEN FORM 2� •09 SHADED AREAE FOR EHD u3E ONLY OWNER IDB o un o k�T 1 4 CASE# UNIT I V U V OWNI ER FILE CoMPLETETHEFoccowNi;PROPERTY OWNER INFoRwnoAt.• CHECmir OWNER CL1RA£AfnyoovFaE»fr+EHO PROPERTY OWNER NAME ELLIOT M MEGDAL PHONE (310) 277-0456 Frst M! I Last BUSINESS Nime EBM INVESTMENTS, a CaU6oniva genehat patc.tneAsh-k'p SocSEc/TAxIDB 26-2771657 owner Horne Address 9221 HA Z EN DRIVE DRIVER'S LICENSE B M 0 6 2 8 5 0 1 City BEVERLY HILLS STATE CA nP 90210 Owner Mailing Address 1875 CENTURY PARK EAST, #1840 MailingAddreseclty LOS ANGELES, CA 90067 state Ca Zip 90067 CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP[ FED AcENcy❑ OTHER(❑ FACILITY FILE FACILITY ID B T,\�n/� CROSS REF ID B AccouNr 10 B 1 R�pD 3 5 3 o S INI y `j CompiETEn+EFoLcowtNG BUSINESS/FACILITY/SITE INFoRIwAnow Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPT.? YES ❑ No Is this an ExtSTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No Bus wss/FACLL.RY/SITE NAME Sm ADDREss 6632 PACIFIC AVENUE SURE B BUSINESS PHONE CITY STOCKTON STATE CA 71 95207-3720 BoARo OF Sut>'ERvism DtsTRICT LocATioN Com KEYS KEY2 Melling Address/fD/FFEREA(TkwnFwc+WdAabhsas Attention:or Care Of /J 1 CENTURY PARK EAST #1840 ELLIOT ME6 AL Mailing Address City LOS ANGELES STATE CA 7- 90067 SIC COOS APN B COMMENT: 081-260-20 THIRD PARTY BILLING INFO: Complete ifBilling Party is different from Property Owner or Facility Operator identified above. BtISINEss NAPE S 1 Attention:orCare Of(Dptlwl�/J V-\U L-3 N✓ r o nJ�"1 C.� l i.tit t e CS Melling Address 3 ? /C � e/S Ohl (Dr - d PHONE /G/�� 6.6,O 5—y 9 CITY �.V (('_�J STATE G rte- 2w d[X�Ot�/iy95 for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING BILLIVC ASD COMPLIAVCE A('K.V0%kl.FI)(:M1IFVT: I,the undersigned Applicant,certify that 1 am the(M-ner.Operator.or Aurhoriced Agetu of this Business,and I acknowledge that all Pt.R.tftr rets. Ptrvu.Its',F�etrxevearnT CR(Rets and/or Hot'Rt.)CH)RG/Cv associated with this operation will he billed to me at the address identified-hove as t e 71 cot v Annxres for this site. I also certify that all information provided on this application is Ie and correct:and that all regulated activities will be performed in accordance with all a III able SSS Jo tst)oIv C' �n O finance Codes and/or Standards and STA I F and/or FEDI-RAI Laws and Regulations. As the undersigned owner,operator,or agent of the property located e e faciiit sit addrrs I h reb thorize the release of ane and all results and environmental assessment information to SAN JOAQtIIN COUNTY ENV'IRONMIEN1 AL HEAL IH D AR I"I ron it is r.iiable a at the same time it is pro%ided to me or my representative. APPLICANT NAME ELLIOT M EGDA L PLEASE PRo r SIGNATURE TITLE GENERAL PARTNER DRIVER'S LICENSE# 110628 1 (PHOTOCOPY REQUIRED) APW'od BY DtNs ORk:a By Data '9-P' in 11 a- !dASI'1'2R I'll F RECORD-GRFL'N N�I��N11A� �0