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Date run 9/25/2018 1:03:03PN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 9/25/2018 <br /> Record Selection Criteria: Facility ID FA0000081 <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/Fed Tax ID <br /> Owner ID OW0000069 New Owner ID <br /> Owner Name YOUNGS LOCKEFORD PAYLESS MKT <br /> Owner DBA YOUNG'S LOCKEFORD PAYLESS MARK <br /> Owner Address 18980 N HWY 88 <br /> LOCKEFORD, CA 95237 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-727-0166 <br /> Mailing Address PO BOX 122 <br /> LOCKEFORD, CA 95237 <br /> Care of YOUNG, KENNETH <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0000081 10180525 <br /> Facility Name YOUNGS LOCKEFORD PAYLESS MARKET <br /> Location 18980 N HWY 88 <br /> LOCKEFORD, CA 95237 <br /> Phone 209-727-5551 x <br /> Mailing Address PO BOX 122 <br /> LOCKEFORD, CA 95237 <br /> Care of YOUNG, KENNETH <br /> Location Code 99- UNINCORPORATED A Alt Phone <br /> BOS District 004 -WINN, CHARLES Fax <br /> APN 05130023 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name YOUNGS PAYLESS MKT <br /> Title <br /> Day Phone 209-727-5628 <br /> Night Phone 209-727-5628 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0000080 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name YOUNGS LOCKEFORD PAYLESS MARKET (Circle One) <br /> Account Balance as of 9/25/2018: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1619-RETAIL MKT>1000 SID FT(=/>2 DEPTS) PRO161914 EE0078788-GEHANE FAHMY Active Y N A D <br /> 1920-HMBP-Common Materials PR0521052 EE0008709-JAMIE LIMA Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PR0517781 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE FI PR0517782 EE0000149-RAYMOND BORGES InactivE Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGI PR0534637 InactivE Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENTI,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific,PHS/EHD hourly charges associated with this facility <br /> 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 <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 b p <br /> EHD Staff: I 1MA _ Date�(�Z/1� Account out: Date <br /> COMMENTS: Ir1V01Ce#: <br />