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Dale run 5/2812015 9:13:30At, SAN JO IN COUNTY ENVIRONMENTAL HEA.[DEPARTMENT Report 9501 <br /> Pagel <br /> Run by Facility Information as of 5/28/2015 <br /> Record selection Criteria: Facility ID FA0003183 <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: 4 SSN/Fed Tax ID <br /> Owner ID OW0010964 New Owner ID <br /> Owner Name 99 Cents Only Stores <br /> Owner DBA <br /> Owner Address 4000 UNION PACIFIC AVE <br /> COMMERCE, CA 90023 <br /> Home Phone 323-980-8145 <br /> Work/BusinessPhone 323-980-8145 <br /> Mailing Address 4000 Union Pacific Avenue <br /> Commerce, CA 90023 <br /> Care of TAX DEPARTMENT <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0003183 10440307 <br /> Facility Name 99 Cents Only Stores#185 <br /> Location 1320 W 11th St <br /> Tracy, CA 95376 <br /> Phone 209-839-9619 x <br /> Mailing Address 4000 Union Pacific Avenue <br /> Commerce, CA 90023 <br /> Care of 99 Cents Only Stares <br /> Location Code 03 -TRACY Alt Phone <br /> BOS District 005 - ELLIOTT, BOB Fax <br /> APN EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name JERRY GESS <br /> Title <br /> Day Phone 209-839-9619 <br /> Night Phone 323-980-8150 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0002751 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> (Circle One) <br /> Account Name Paul Dolby <br /> Account Balance as of 5/28/2015: $0.00 (Circle One) <br /> Transfer to Active/InacNe <br /> PrograMElemeM and Description <br /> Record ID Employee ID and Name Status New Owner? Delete <br /> 1618-RETAIL MKT>2000 SO FT (PREPKGD/LTD PRE PRO161629 EE0001420-MELISSA NISSIM Active Y N A I D <br /> 1921 -HMBP-Regular-Primary Location PR0539370 EE0002474-MICHAEL PARISSI Active Y N A I D <br /> 2220-SM HW GEN<5 TONSNR PR0538450 EE0005642-MICHELLE HENRY Active 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,PHSEHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on thisform l also certify that all operations will be performed in accordance with all applicable Ordinance Codes andror Standards and State anwor <br /> Federal Laws. <br /> APPLICANT'S 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 Received by <br /> EHD Staff: Date_/_/_ Account out: Date <br /> COMMENTS: Invoice#: <br />