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SAN >10AQUIN Environmental Health Department <br /> COMMERCIAL CANNABIS LICENSE APPLICATION <br /> PART B — OWNER INFORMATION <br /> LEGAL BUSINESS NAME: <br /> Cultiva, LLC <br /> BUSINESS PHYSICAL ADDRESS: OCALON <br /> Y: STATE: ZIP CODE: <br /> 12811 Droge Road, Building D CA 95320 <br /> OWNER INFORMATION <br /> Complete the information below for each owner as defined in 4-10005(o). Total Number of Legal 2 <br /> Owners: <br /> OWNER# of <br /> OWNER LEGAL LAST NAME: OWNER LEGAL FIRST NAME: BUSINESS TITLE: <br /> Nguyen Leon D T Owner <br /> PHONE NUMBER: EMAIL ADDRESS. DATE OWNER ACQUIRED % OF OWNERSHIP: <br /> INTEREST: <br /> 408-668-5158 Leondt@gmaii.com 50 <br /> OWNER CANNABIS FINANCIAL INTERESTS - List all state issued cannabis license(s) the owner holds an <br /> ownership or financial interest in. Attach additional. <br /> TYPE OF LICENSE ISSUED BY TYPE OF LICENSE ISSUED BY <br /> LICENSE NUMBER LICENSE NUMBER <br /> N/A N/A N/A N/A N/A N/A <br /> DISCLOSURES <br /> Provide the information below for all convictions and attach a detailed description of the offense for which you <br /> were convicted. (4-10011(a)(b)) <br /> <br /> <br /> <br /> <br /> <br /> <br /> : <br /> OWNER ATTACHMENTS <br /> ❑ Copy of government issued identification. <br /> OWNER DECLARATIONS <br /> 1 1 understand that I am responsible for knowing and complying with all California state and local laws and <br /> regulations applicable to commercial cannabis. <br /> 2. 1 understand I am responsible for compliance with subsequent updates to cannabis laws and regulations. <br /> 3 1 hereby declare the information contained within and attached to this application is complete, true, and <br /> accurate. <br /> 4 1 understand a misrepresentation of fact is cause for rejection of this application, denial of the license, or <br /> revocation of an issued license <br /> OWNER SIGNATURE: DATE:11/12/2020 <br /> PRINT NAME:Leon Nguyen <br /> SR ID: FACILITY ID: <br /> PE CODE: PROGRAM RECORD ID: <br /> 7-29-2019 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/EHD <br />