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Date run 10!612015 11:40:27AI SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 10/6/2015 <br /> Record Selection Criteria: Facility ID FA0009107 <br /> Make changeslcorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID <br /> Owner ID OW0007107 Case Number: H01257 New Owner ID <br /> Owner Name CENTRAL VALLEY HARDWARE CO <br /> Owner DBA CENTRAL VALLEY HARDWARE CO <br /> Owner Address 924 E CHURCH ST <br /> STOCKTON, CA 95203 <br /> Home Phone Not Specified <br /> Work]Business Phone 209-464-7305 <br /> Mailing Address PO BOX 2008 <br /> STOCKTON, CA 95201 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility IDlCERS ID FA0009107 <br /> Facility Name CENTRAL VALLEY HARDWARE CO <br /> Location 924 E CHURCH ST <br /> STOCKTON, CA 95203 <br /> Phone 209-464-7305 x0 <br /> Mailing Address PO BOX 2008 <br /> STOCKTON, CA 95201 <br /> Care of <br /> Location Code 01 - STOCKTON Alt Phone <br /> BOS District 001 -VILLAPUDUA, CARLOS Fax <br /> APN 151-280-01 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0016107 New Account ID: <br /> 'Mail Invoices to Owner Mail Invoices to: Owner ! Facility 1 Account <br /> Account Name CENTRAL VALLEY HARDWARE CO (Circle One) <br /> Account Balance as of 1016/2015: $0.00 <br /> ' (Circle One) <br /> Transfer to Activellnactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Reqular-Primary Location PR0519655 EE0000000-HAZ MAT SJC OES inactive Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PR0511395 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PRO509107 Ei;0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0531927 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT. I,the undersigned owner,operator or agent of same,acknowledge that all site,andlor project specific,PH&EHD hourly&arges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this form I also cerVy that all operations wIll be performed in accordance with all applicable Ordinance Codes andlor Standards and Slate andlor <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date ! ! <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date ! ! <br /> Water System to be TRANSFERED: Amount Paid Date ! / <br /> Payment Type Check Number Received by <br /> EHD Staff: Date ! 1 Account out: Date 1 1 <br /> COMMENTS: <br /> Invoice#: <br /> f� <br />