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Date run i 2/20/2043 11:24:01AI SAN J%�UIN COUNTY ENVIRONMENTAL HEAL`, Report#5021 <br /> l DEPARTMENT Paget <br /> Run by <br /> Facility Information as of 2/20/2013 <br /> Record Selection Criteria: Facility ID FA0006164 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> owner ID OW0004913 New Owner ID <br /> Owner Name RAYMOND DISTRIBUTING INC <br /> Owner DBA RAY'S BEVERAGE CO <br /> Owner Address 4218 N CORONADO t At;e BO <br /> STOCKTON, CA 86204 ggao$D�3O <br /> Home Phone Not Specified <br /> Work/Business Phone 209-477-5893 <br /> Mailing Address PO BOX 8489 1 7� <br /> STOCKTON, CA-85268- t <br /> Care of t?5z qu pQ:�� <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0006164 <br /> Facility Name RAYS BEVERAGE COMPANY <br /> Location 4218 N CORONADO AVE <br /> STOCKTON, CA 95204 <br /> Phone 209-466-6883 x0 <br /> Mailing Address 4218 N CORONADO AVE <br /> STOCKTON, CA 4&2e42328' <br /> Care of Z Jr' aD o'� � <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 002 RUHSTALLER, LARRY Fax <br /> APN 11530039 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 AR0007235 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name RAYMOND DISTRIBUTING INC (Circle One) <br /> Account Balance as of 2/20/2013: $320.00 <br /> (Circle One) <br /> Transfer to Active9nactve <br /> Pr raMElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> M <br /> 192 HMBP-Regular-Primary Location PR0519757 EE0009817-ROBERT LOPEZ Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOPPR0511884 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2381 -UST FACILITY(BEFORE 1/84)-obsolete PR0504319 EE0000451 -STEVE SASSON Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHAR(PR0509596 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCH,PR0532524 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT. I,the undersigned owner,operator or agent of same,acknowledge that all site,andror project specific,PHSIEHD 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 Codas andror Standards and State andfor <br /> Federal Laws, <br /> APPLICANTS 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 Recei <br /> REHS: Date_/_/_ Accipunt out Date�2 _/0 Flo /1 <br /> -45 <br /> COMMENTS:Y)l h 1r 3 <br /> O('llO[ �C RUR <br />