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Date run 5/28/2015 9:51:02AN SAN JOr~eUIN COUNTY ENVIRONMENTAL HEA,,.iirI DEPARTMENT Report#5021 <br /> Run by Paget <br /> Facility Information as of 5/28/2015 <br /> Record Selection Criteria: Facility I D FA0014350 <br /> Make changestcorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 12 SSN/Fed Tax ID <br /> Owner ID OW0016236 New Owner ID <br /> Owner Name Longs Drug Stores California, L.L.C. <br /> Owner DBA CVS/PHARMACY <br /> Owner Address 1 CVS DR <br /> WOONSOCKET, RI 02895 <br /> Home Phone 401-770-3315 <br /> Work/Business Phone 401-770-3315 <br /> Mailing Address One CVS Drive <br /> Woonsocket, RI 02895 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0014350 10184615 <br /> Facility Name CVS Pharmacy#3908 <br /> Location 1885 W 11th St <br /> Tracy, CA 95376 <br /> Phone 209-836-1460 x <br /> Mailing Address CVS Health, Attn: Dianne E. Durand, Licensin( <br /> Woonsocket, RI 02895 <br /> Care of Longs Drug Stores California, L.L.C. <br /> Location Code 03 -TRACY Alt Phone <br /> BOS District 005-ELLIOTT, BOB Fax <br /> APN 23217021 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name LICENSING DEPT/DURAND, DIANNE <br /> Title <br /> Day Phone 140-177-0331 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0024383 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility I Account <br /> Account Name CVS Health, Attn: Dianne E. Durand, Licensing (Circle One) <br /> Account Balance as of 5/28/2015: $398.00 <br /> (Circle One) <br /> Transfer AchysilnacNe <br /> Progra"Element and Description Record ID Employee ID and Name Status New Omen Delete <br /> 1615-RETAIL MKT 301-2000 SO FT(PREPKGD/LTD PF PR0519192 EE0001420-MELISSA NISSIM Active Y N A I D <br /> 1921 -HMBP-Regular-Primary Location PR0539027 EE0002474-MICHAEL PARISSI Inactivc Y N A I D <br /> 2200-HAZARDOUS WASTE GENERATOR PROGRAM PR0539026 EEo000000-HAZ MAT SJC OES InactivE Y N A I D <br /> 2240-RCRA ACUTELY HW GEN<5 TONSNR PR0522840 EE0005642-MICHELLE HENRY Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0532724 Inactivc Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,adnowledge that ail site,andor project specific,PHSIEHD hourly charges associated with this facility <br /> or activity will be billed!to the party identified as the OWNER on this forth l also codify that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and State andor <br /> Federal Lewis <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 Received by <br /> EHD Staff: Date I / Account out: Date / ! <br /> COMMENTS: <br /> Invoice#: <br />