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San Joaquin County Environmental Health Department <br /> DATE 11/16/07 MASTER FILE RECORD INFORMATION "MFR"rD, GREEN FORM <br /> xsoeo exewamnEHD <br /> Saverrr D . OWNER IDN oof/f l � UNIT NIT IV <br /> W JkTOJWNER FILE <br /> COMPLETE JNEFOLLOWAV PROPERTY OWN ER/NFORMAnom, CHEC#IF OWNER CURREHTLYONN45W HEHD <br /> PROPERTY OWNER S.�,t,� Ltd PHONE 209-478-1791 <br /> NAME <br /> l1 11 <br /> post Mf last <br /> BUSINESSNAME ROSINHOOD PLAZA SHOPPING CENTER SOc SEC/TABID# TAXID <br /> Owner Home Address 1024 W.Robinhood Drive,Ste.411 DRNER'S LICENSE# <br /> City Stockton STATE CA ZIP 95207 <br /> owns,Mailing Aaar.o 1024 W.Robinhood Drive,Ste.#1 <br /> Mailing Address City Stockton State CA Zip 95207 <br /> CORPORATION❑ INDIVIDUAL El PARTNERSHIPXX❑ FED AGENCY C1 OTHER[I <br /> FACILITY FILE <br /> FACILITYID# �4.. �,5 CROSSREFID# ACCOUNTID# O 331 5 INV# <br /> COMPLETE7NEFOLLOWJNO BUSINESS I FACILITY/SITE INFORMAT/oN.' <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? yes ❑ No ❑ <br /> Isthlsan EXISTING Business LOCATION but a NEWTYPE of regulated Business? YES ❑ NO ❑ <br /> BUSINESSIFACILRYISRENAME ROBINHOOD PLAZA SHOPPING CENTER /-14 <br /> SITEADDRESS 5756 PACIFIC AVENUE SUITE# BUSINESS PHONE 478-1791 <br /> CITY STOCKTON STATE CA ZIP 95207 <br /> IIBOARD OF SUPERVIsoa DISTRICT I I LOCATION CODE I I KEY1_ I I KEY2 <br /> Mailing Address HO/FFERENTBwRFwAllyAddrsss 1024 W. Robinhood Drive. Attention:of Care Of(opNpw/J <br /> Mailing Address City Stockton STATE CA ZIP 95207 <br /> SIC CODE APN# IOL. 2-10-1:'Q COMMENT: - <br /> THIRDPARTYBILLINGINFO: Complete if Billing Party is different from Property Owner or Facility operator idenvrledabove. <br /> BUSINESS NAME Attention:orCare Of (oplbone/J <br /> Mailing Address PHONE <br /> CITY STATE ZIP <br /> At2CCOXzADAl forfees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> RILLi\NG ANO CONIEL1AYCF.ACX,Vowl.EDGNEYT: I,the undersigned Applicant,certify that 1 am the Owner,Operator,or kaborieed Agent of this Business,and 1 nelelonledge that ail P£R.mTFEFs, <br /> PEW4Lrr£S,ENF0RC£.II£NTCILIRCF9 and/or HOURLYCv uu;ES associated Nilh this eperANOn nill be billed to melt the address Identified above z the/ICMn , ADDR£cs for this site. I also certify that all <br /> information provided on Ibis application is true and correct;and that ail regulated activities wgl be performed in accordance xith all applicable SAH JOAQBLN Co11.vTY Ordinance Codes and/or <br /> Standards and STATE vndlur FEDERAL Lm v and Regulation. As the undersigned owner,operator,or agent of the property located at the above facility/site address,f hereby authorize the release of <br /> say and all results and envim eavotal 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 PRINT ,r <br /> APPLICANT NAME JAY ALLEN SIGNATURE <br /> TITLE l� DRIVER'S LICENSE# <br /> (PHOTOCOPY REOUIRED) <br /> Approved By Date Accounting Office Processing Completed Bim / p-7 <br />