HomeMy WebLinkAbout952139.tiffDILL DILL CARR STONBRAKER & HUTCHINGS
A PROFESSIONAL CORPORATION
ATTORNEYS AT LAW
September 14, 1995
Weld County
Liquor Licensing Divison
915 10th Street
Greeley, Colorado 80632
RE: Manager Notification
Metro Oil, Inc. d/b/a Total #2748
Dear County Clerk:
Daniel W. Carr
John J. Coates
H. Alan Dill
Robert A. Dill
Thomas M. Dunn
John A. Hutchings
Leslie Block Kaye
Casey D. Paison
Jon Stonhraker
Patrick D. Tooley
The purpose of this letter is to notify Weld County that the manager for the above
referenced location has changed.
The new manager is Leroy Meckelburg and I have enclosed a copy of his Individual
History Record for your files.
Should you have any questions please do not hesitate to call me.
Connie A. Brands/Paralegal
Dill, Dill, Carr, Stonbraker & Hutchings, P.C.
Enc
1ZS
455 SHERMAN STREET, SUITE 300 / DENVER, COLORADO 80203 / FAX (303) 777-3823 / (303) 777-3737
DR 8404-I (02/94)
COLORADO DEPARTMENT OF REVENUE
LIQUOR ENFORCEMENT DIVISION
1375 SHERMAN STREET
DENVER CO 80261
INDIVIDUAL HISTORY RECORD
To be completed by each individual applicant, all general partners of a partnership, all limited partners owning 10% (or more) of a
partnership; all officers and directors of a corporation, all stockholders of a corporation owning 10% (or more) of the stock of such
corporation; all limited liability company MANAGING members, or other limited liability company members with a 10% (or more)
ownership interest In such company and all managers of a Hotel and Restaurent 11
canes.
NOTICE: This individual history record provides basic information which is necessary for the licensing authorities investigation. ALL questions
must be answered in their entirety. EVERY answer you give will be checked for its truthfulness. A deliberate falsehood will Jeopardize the
application as such falsehood within itself constitutes evidence regard ng the character of the applicant.
1. Name Business
of
METRO OIL, INC.
2. Your Full Name I
Date
9/12/95
Soca Security Number(s)
(last, first, middle)
MEKELBURG, JR., LEROY AUGUST
4. Mailing Address
3. Also Known As (maiden name/nickname, etc.)
LEROY
(if different from residence)
SAME
5. Residence
Home Telephone
280-1870
Address (street and number,
12007 NEWPORT DRIVE,
6. Date of Birth
city, state, ZIP)
BRIGHTON, CO 80601
If Naturalized,
Place of Birth
CHARLESTON, SOUTH CAROLINA
7. U.S. Citizen?
',21
Yes ❑
state where
N/A
Naturalization
When
No
Name of U.S. District Court
N/A
8. Height
Certificate Number
Date of Certificate
II an Alien, O Alien'
Alien's Registration Card Number
Permanent Residence Card Number
6'
10. Name
Weight
185
Present
Hair Color
BROWN
Eye Color
BLUE
Sex
MALE I
Race
CAUL
9. Do You Have a current Drivers License?
Xi Yes Nm
of Employer❑
METRO OIL, INC.
12. Address
11. Type of Business or Employment
CONVENIENCE STORE
of Business Where Employed (street number, city, state, ZIP)
5590 S. HAVANA, DENVER, CO 80239
Present
Business Telephone
373-6000
13. Position
DISTRICT MANAGER
14. Marital Status
MARRIED
15. Name of Spouse (include maiden name if applicable)
LAURA MAE (WEST) MEKELBURG
16. Spouse's Date of Birth
Spouse's Place of Birth
COLORADO SPRINGS, CO
17. Spouse's residence address, if different than yours (street and number, city, state, ZIP)
SAME
18. Spouse's Present Employer
NOT EMPLOYED OUTSIDE THE HOME
Occupation
HOUSEWIFE
19. Address of Spouse's Present Employer
N/A
20. List the name(s) of all relatives working in or having a financial interest in the liquor industry.
NAME OF RELATIVE
RELATIONSHIP TO YOU
POSITION HELD
NAME OF EMPLOYER
LOCATION OF EMPLOYER
NONE
21. Do you now, or have you ever held a State of Colorado Liquor or Beer License, or loaned money, furniture, fixtures, equipment or inventory, to any Colorado Liquor or Beer
Licensee? If yes, answer in detail
❑ Yes Li No
E SIDE
22.
Have
violations,
explain
4i
you ever been convicted of a crime, or received a suspended sentence, deferred sentence, or forfeited bail for any offense in criminal or military court? (Do not include traffic
unless they resulted in suspension or revocation of your drivels license, or you were convicted of driving under the influence of drugs or alcoholic beverages.) If yes,
in detail.
Yes ❑ No DRIVER'S LICENSE WAS SUSPENDED IN 1982 AS A RESULT OF TOO MANY TRAFFIC
VIOLATION POINTS.
23. Have you ever received a violation notice, suspension or revocation for a liquor law violation, or been denied a liquor or beer license anywhere in the U.S.? II yes, explain in detail.
❑ Yes Ot No
24. Military Service (branch)
NONE
From
To
Serial Number
Type of Discharge
25.
List all addresses where you have lived for the past five years. (Attach separate sheet if necessary)
STREET AND NUMBER
CITY, STATE, ZIP
FROM
TO
12007 NEWPORT DRIVE
BRIGHTON, COLORADO 80601
1993
PRESENT
860 WEST 132ND AVENUE, #15
DENVER, COLORADO 80234
1990
1993
2s. List all former employers or businesses engaged in within the last five years. (Attach separate sheet
if necessary.)
NAME OF EMPLOYER
ADDRESS (STREET, NUMBER, CITY, STATE, ZIP)
POSITION HELD
FROM
TO
HAVE BEEN EMPLOYED WITH METRO OIL,
INC. FOR THE PAST FIVE YEARS
27. What is your relationship to the applicant? (sole owner, partner, corporate officer, director. stockholder, member or manager)
DISTRICT MANAGER
28. If stockholder, number of shares owned beneficially or of record
N/A
Percent of outstanding stock owned
29. It partner, state whether 0 General
N/A
• Limited
Percent of Partnership Owned
IIf Limited Liability Company (percent owned)
30. Total amount you will invest in this business, including notes, loans, cash, services or equipment, and operating capital. (Reg.48-106.1 and Reg. 47-107.1)
Amount $ —0-
31 Identity the sources of all funds you will invest in this business as listed in 30 above. List ail bank names,
account numbers and the amount derived from such source. Also identify all persons authorized to sign on,
or who are part owners of said account. (Attach copies of all your notes or loans used in or for this business.)
I Alamws cm accounts or person who can
Amounts
NONE
Sources - Account Numbers
sign on this account
Oath of Applicant
I declare under penalty of perjury in the second degree that this application and all attachments are true, correct, and complete to the best
of my knowledge.
Authorized Signature
a.
Title
Date
la -SS
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