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Date run 4/27/2016 8:59:05AN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report #5021 Run by Pagel Facility Information as of 4/27/2016 Record Selection Criteria: Facility ID FA0012655 OWNER FILE INFORMATION Number of facilities for this owner: Owner ID OW0009852 Owner Name BONADONNAS ASPHALT REPAIR Owner DBA Y N Owner Address 3883 S EL DORADO ST Inactive STOCKTON, CA 95206 Home Phone Not Specified Work/Business Phone 209-982-1804 Mailing Address PO BOX 6377 STOCKTON, CA 95206 Care of FACILITY FILE INFORMATION Facility ID / CERS ID FA0012655 10184313 Facility Name BONADONNAS ASPHALT REPAIR Location 3883 S EL DORADO ST STOCKTON, CA 95206 Phone 209-982-1804 x Mailing Address PO BOX 6377 STOCKTON, CA 95206-0377 Care of Bonadonna's Asphalt Repair Inc Location Code 01-STOCKTON Bos District 001 - VILLAPUDUA, CARLOS APN 17525056 EMERGENCY NOTIFICATION CONTACT INFORMATION Contact Name DAVID BONADONNA Title PRESIDENT Day Phone 209-982-1804 Night Phone 209-993-3159 ACCOUNTS RECEIVABLE FILE INFORMATION Account ID AR0020956 Mail Invoices to Account Account Name BONADO ASPHALT REPAIR Account Balance as of 4/27/201: $620.5 MlDvt Make changes/corrections in RED ink. INFORMATION CHANGE (date) OWNERSHIP CHANGE (date) SSN / Fed Tax ID New Owner ID : Alt Phone Fax EMail : New Account ID: : Mail Invoices to: Owner / Facility / (Circle One) V ` ,3q2 s ,o �� Program/Element and Description Record ID Employee ID and Name 1921 - HMBP-Regular-Primary Location PRO530820 EE0009817 - ROBERT LOPEZ 2220 - SM HW GEN <5 TONS/YR PR0538939 EE0001421 - STACY RIVERA 2399 - UNIFIED PROGRAM FAC STATE SURCHARGE F PRO516519 EE0000451 - STEVE SASSON 2831 - AST FAC >/= 1,320 - <10 K GAL CUMULATIVE PRO516518 EE0001421 - STACY RIVERA ERSC - ELECTRONIC REPORTING STATE SURCHARG PRO532976 Account (Circle One) Active/Iractve Delete A I D A I D A D A I D A I D BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, and/or project specific, PHS/EHD hourly charges associated with this facility 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 Federal Laws. APPLICANT'S SIGNATURE: Date Program Records to be TRANSFERED: ` $25.00 = Amount Paid Date Water System to be TRANSFERS . Amount Paid Date Payment Ty a eck Number Received b ' I EHD Staff: Date l --,Il Account out: Date COMMENTS: Invoice #✓: Transfer to Status New Owner? Active Y N Active Y N Inactive Y N Active Y N Inactive Y N Account (Circle One) Active/Iractve Delete A I D A I D A D A I D A I D BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, and/or project specific, PHS/EHD hourly charges associated with this facility 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 Federal Laws. APPLICANT'S SIGNATURE: Date Program Records to be TRANSFERED: ` $25.00 = Amount Paid Date Water System to be TRANSFERS . Amount Paid Date Payment Ty a eck Number Received b ' I EHD Staff: Date l --,Il Account out: Date COMMENTS: Invoice #✓: