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Date run 4/6/2017 11:39:27AM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 Run by DONNA Pagel Facility Information as of 4/6/2017 Record Selection Criteria: Facility ID FA0011113 OWNER FILE INFORMATION Number of facilities for this owner: 1 Owner ID OW0009113 Case Number: H09300 Owner Name Baker Distributing Company Owner DBA 2399 - UNIFIED PROGRAM FAC STATE SURCHARGE F Owner Address 4610 BREAKERS DR 203-833-3705 x JACKSONVILLE, FL 32258 Home Phone 904-407-4367 Work/Business Phone 904-407-4499 Mailing Address 14610 Breakers Drive 99 - UNINCORPORATED P Jacksonville, FL 32258 Care of WILSON, JENNIFER FACILITY FILE INFORMATION Facility ID / CERS ID FA0011113 10195759 Facility Name Baker Distributing Branch 600 Location 25882 S Corporate Ct 2399 - UNIFIED PROGRAM FAC STATE SURCHARGE F Tracy, CA 95377 Phone 203-833-3705 x Mailing Address 25882 S. Corporate Ct BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, and/or project speci Tracy, CA 95377 Care of Baker Distributing Company # 600 Location Code 99 - UNINCORPORATED P BOS District 005 - ELLIOTT, BOB APN A EMERGENCY NOTIFICATION CONTACT INFORMATION Contact Name BRAD TRACY Title MANAGER Day Phone 209-833-3705 Night Phone 209-496-5313 ACCOUNTS RECEIVABLE FILE INFORMATION Make changes/corrections in RED ink. INFORMATION CHANGE (date) OWNERSHIP CHANGE (date) SSN /Fed Tax ID New Owner ID : Alt Phone Fax EMail : Account ID AR0018113 Mail Invoices to Account Mail Invoices to Account Name Jen "r Wilson Account Balance as of 4/6/20 7: $405.40 Program/Element and Description Record ID Employee ID and Name New Account ID: : Owner / Facility / Account (Circle One) 1921 - HMBP-Regular-Primary Location PRO520678 EE0000009 - NICHOLAS LOEHRER 2224 - HAZ MAT BUSINESS PLAN AUTHORIZATION PR0513401 EE0000000 - HAZ MAT SJC OES 2399 - UNIFIED PROGRAM FAC STATE SURCHARGE F PRO511113 EE0000000 - HAZ MAT SJC OES 4740 -WASTE TIRE SITE - EXEMPT PR0535348 EE0002620 - ALFONSO ARAMBULA BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, and/or project speci 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 Federal Laws. Inactive Y N APPLICANT'S SIGNATURE: Program Records to be TRANSFERED: Water System to be TRANSFERED: Payment Type Check Number EHD Staff: COMMENTS: ' $25.00 = Date Date / !. Amount Paid Date _ Amount Paid Date Received by Account out: Date Invoice #: (Circle One) Transfer to Active/Inactve Status New Owner? Delete Inactive Y N A I D Inactive Y N A I D Inactive Y N A I D Inactive Y N A I D PHS/EHD hourly corarges associated with this facility )rdinance C and/or Standards and State and/or Date / !. Amount Paid Date _ Amount Paid Date Received by Account out: Date Invoice #: