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Date run 7119/2017 9:28:55AK SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH,DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 7/19/2017 <br /> Record Selection Criteria: Facility 10 FA0019466 <br /> (Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner : 1 SSN 1 Fed Tax ID <br /> Owner ID OW0015954 New Owner ID <br /> Owner Name CHARLES ANSELMI <br /> Owner DBA COUNTRY CLUB HARDWARE <br /> Owner Address 1939 COUNTRY CLUB BLVD <br /> STOCKTON, CA 95204 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-464-8285 <br /> Mailing Address 1939 COUNTRY CLUB BLVD <br /> STOCKTON, CA 95204 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID I CERS ID FA0019466 10187247 <br /> Facility Name COUNTRY CLUB HARDWARE <br /> Location 1939 COUNTRY CLUB BLVD <br /> STOCKTON, CA 95204 <br /> Phone 209-464-8285 x0 <br /> Mailing Address 1939 COUNTRY CLUB BLVD <br /> STOCKTON, CA 95204 <br /> Care of charles anselmi <br /> Location Code 99 - UNINCORPORATED A Alt Phone <br /> BOS District 001 -VILLAPUDUA, CARLOS Fax <br /> APN 12315430 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 AR0034616 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner I Facility 1 Account <br /> Account Name COUNTRY CLUB HARDWARE (Circle One) <br /> Account Balance as of 7/19/2017: $0.00 <br /> (Circle One) <br /> Transfer to ActivOlnactve <br /> Program/Element and Description Record ID Employee lD and Name Status New Owner? Delete <br /> 1920-HMBP-Common Materials PRO529199 EE0009817-ROBERT LOPEZ Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGi PRO533566 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project speck,PHSIEHD hourly charges associated with this facility <br /> or activity wit be billed to the party identified as the 6WNER on this farm. I also certify that alloperations will be performed in accordance with all applicable Ordinance Codes and/or Standards and State and/or <br /> Federal Laws_ <br /> APPLICANT'S SIGNATURE: Date 1 f <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date 1 I <br /> Water System to be TRANSFERED: Amount Paid Date I 1 <br /> Payment Type Check Number Received by <br /> EHD Staff: Date i 1 Account out: Date 1 1 <br /> COMMENTS, <br /> Invoice#: <br />