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ecce run 2/10/2016 4:33:26PN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 Run by Pagel Facility Information as of 2/10/2016 Record Selection Criteria: Facility ID FA0009519 OWNER FILE INFORMATION Number of facilities for this owner: 1 Owner ID OW0007519 Case Number: H04697 Owner Name, ±O MFS—FD0DS-CORP Owner DBA Owner Address 1 S HORMET PL AUSTIN, MN 55912 Home Phone 507-437-5955 Work/Business Phone 5,07-437-5611 Mailing Address AUSTIN, MN 55912 Care of HORMEL FOODS CORPORATION FACILITY FILE INFORMATION Make changes/corrections in RED ink. INFORMATION CHANGE (date) OWNERSHIP CHANGE (date) SSN /Fed Tax ID New Owner ID : "A4 Lo — LC, t�,oa•� �. r Q�a� Facility ID / CERS ID FA0009519 10182749 Facility Name C ('t -i. Location 1404 S FRESNO AVE zva `7, S- rrr3rV STOCKTON, CA 95206 S Phone 209-943-5411 x Oelj 66";L— Go.lo Mailing Address PO BOX 100 STOCKTON, CA 95201 Care of Ken Feldman SS Location Code 01 - STOCKTON Alt Phone 373rz/— j �? BOS District 001 - VILLAPUDUA, CARLOS Fax APN 16337018 EMail: Skn,53. Ile C— Mtuk)bw Coh-1 EMERGENCY NOTIFICATION CONTACT INFORMATION Contact Name Title Day Phone Night Phone ACCOUNTS RECEIVABLE FILE INFORMATION Account ID AR0016519 New A unt ID: Mail Invoices to Account Mail Invoices to: Owner / acility / Account Account Name HORMEL FOODS CORP Circle One) Account Balance as of 2/10/2016: $518.00 (Circle One) Transfer to Active/Inactve Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete 1921 - HMBP-Regular-Primary Location PR0519695 EE0009817 - ROBERT LOPEZ Active Y N A I D 2220 - SM HW GEN <5 TONS/YR PR0513881 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 ACKNOWLED MENT: I, th undersigned owner, operator or agent of same, acknowledge that all site, ancLor project specific, PHS/EHD hourly charges associated with this facility or activity will be billed to the party identifie s t WN 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 SIGNATU Date / 1 Program Records to b FERED: * $25.00 = Amount Paid Date Water System to be TRANSFI�RED: Amount Paid Date Payment Type Check Number Received by EHD Staff: Date. -7- Acco t out: Date COMMENTS: —�/ � ll—�fll Invoice #: