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Gntcrun ' 2/19/2016 10;05:41AI SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 Run by Pagel Facility Information as of 2/19/2016 Record Selection Criteria: Facility ID FA0009519 OWNER FILE INFORMATION Number of facilities for this owner: 1 Owner ID OW0007519 Case Number: H04697 Owner Name HORMEL FOODS CORP Owner DBA Delete Owner Address 1 S HORMET PL EE0009817 - ROBERT LOPEZ AUSTIN, MN 55912 Home Phone 507-437-5955 Work/Business Phone 507-437-5611 Mailing Address 1 HORMEL PLACE Active AUSTIN, MN 55912 Care of HORMEL FOODS CORPORATION FACILITY FILE INFORMATION Facility ID / CERS ID FA0009519 10182749 Facility Name HORMEL FOODS CORPORATION Location 1404 S FRESNO AVE 2399 - UNIFIED PROGRAM FAC STATE SURCHARGE F STOCKTON, CA 95206 Phone 209-943-5411 x Mailing Address PO BOX 100 I D STOCKTON, CA 95201 Care of Ken Feldman Location Code 01-STOCKTON Bos District 001 - VILLAPUDUA, CARLOS APN 16337018 EMERGENCY NOTIFICATION CONTACT INFORMATION Contact Name Title Day Phone Night Phone ACCOUNTS RECEIVABLE FILE INFORMATION Account ID AR0016519 Mail Invoices to Account Account Name HORMEL FOODS CORP Account Balance as of 2/19/2016: $518.00 Make changes/corrections in RED ink. INFORMATION CHANGE (date) OWNERSHIP CHANGE (date) SSN / Fed Tax ID New Owner ID : Alt Phone Fax EMail : Mail Invoices to: New Account ID: : Owner / Facility / Account (Circle One) (Circle One) Transfer to Active/Inactve Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete 1921 - HMBP-Reqular-Primary Location PR0519695 EE0009817 - ROBERT LOPEZ Active Y N A I D 2220 - SM HW GEN <5 TONS/YR PRO513881 EE0001421 - STACY RIVERA Active Y N A I D 2224 - HAZ MAT BUSINESS PLAN AUTHORIZATION PR0511807 EE0000000 - HAZ MAT SJC OES Inactive Y N A I D 2399 - UNIFIED PROGRAM FAC STATE SURCHARGE F PR0509519 EE0000000 - HAZ MAT SJC OES Inactive Y N A I D 2840 - AST EXEMPT FAC < 1,320 GAL PR0516366 EE0001421 - STACY RIVERA Inactive Y N A I D ERSC - ELECTRONIC REPORTING STATE SURCHARG PR0531606 Inactive Y N 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 andlor Federal Laws. APPLICANT'S SIGNATURE: Date Program Records to be TRANSFERED: Water System to be TRANSFERED: Payment Type Check Number EHD Staff: COMMENTS: ' $25.00 = Date Amount Paid Date _ Amount Paid Date Received by Account out: Date Invoice #: