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Date run 2/8/2017 10:56:29AIV SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 2/8/2017 <br />Record Selection Criteria: Facility ID FA0014724 <br />OWNER FILE INFORMATION Number of facilities for this owner: 1 <br />Owner ID <br />OW0011735 <br />Owner Name <br />BOBOLI INTERNATIONAL INC <br />Owner DBA <br />BOBOLI INTERNATIONAL LLC <br />Owner Address <br />3704 CORONADO AVE <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />STOCKTON, CA 95204 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />209-463-6290 <br />Mailing Address <br />3704 CORONADO AVE <br />APN <br />STOCKTON, CA 95204 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID FA0014724 10184787 <br />Facility Name BOBOLI INTERNATIONAL LLC <br />Location <br />3704 CORONADO AVE <br />Title <br />STOCKTON, CA 95204 <br />Phone <br />209-463-6290 x0 <br />Mailing Address <br />3704 CORONADO AVE <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />STOCKTON, CA 95204 <br />Care of <br />Monica Avalos <br />Location Code <br />Account Name <br />BOS District <br />002 - MILLER, KATHERINE <br />APN <br />11530055 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Tom Herrmann <br />Title <br />Facility Manager <br />Day Phone <br />209-473-3507 <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID <br />AR0025031 <br />Mail Invoices to <br />Account <br />Account Name <br />BOBOLI INTERNATIONAL LLC <br />Account Balance as of 2/8/2017: <br />$344.00 <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />SSN /Fed Tax ID <br />New Owner ID : <br />Alt Phone <br />Fax <br />EMail : <br />So "1 PC\c I C- <br />� ve <br />S -�, t,in- \,L �- kn,-� [,A Q 5"ao7 - 3? 1 <br />Mail Invoices to <br />New Account ID: : <br />Owner / Facility / Account <br />(Circle One) <br />(Circle One) <br />Transfer to Active/Inactve <br />Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br />1921 - HMBP-Reqular-Primary Location PR0521650 EE0009817 - ROBERT LOPEZ Active Y N A I D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARG PRO531338 Inactive Y N A I D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT. I, the undersigned owner, operator or agent of same, acknowledge that all site, anrUor project specific, PHS/EHD hourly charges associated with this facility <br />or activity will be billed to the party identified as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes and/or Standards and State and/or <br />Federal Laws <br />APPLICANT'S SIGNATURE: <br />Program Records to be TRANSFERED: <br />Water System to be TRANSFERED: <br />Payment Type Check Number <br />EHD Staff: <br />COMMENTS: <br />" $25.00 = <br />Date <br />Date <br />Amount Paid Date -/-/ <br />_ Amount Paid Date <br />Received by <br />Account out: Date / /j L -7 -- <br />Invoice #: <br />AA &"' \ % F.J5 0,aA-455 G L.0%t-J15le CvS 'er- 0'GA"1`A v'--.' \ , <br />