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Date run 2/14/2016 5:05:36PIt SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 2/14/2018 <br /> Record Selection Criteria: Facility ID FA0023749 <br /> Make changestcorrections 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 OW0022083 New Owner ID <br /> Owner Name Melissa & Doug, LLC <br /> Owner DBA MELISSA& DOUG LLC <br /> OwnerAddress 25451 MOUNTAIN HOUSE PKWY <br /> TRACY, CA 95377 <br /> Home Phone 209-830-7900 <br /> Work/Business Phone 203-762-4500 <br /> Mailing Address P.O. BOX 590 <br /> Westport, CT 06881 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS to FA0023749 10716526 <br /> Facility Name Melissa& Doug, LLC (overflow-2) <br /> Location 810 Gilmore Ave <br /> Stockton, CA 95203 <br /> Phone 203-762-4500 x <br /> Mailing Address P.O. Box 590 L2 <br /> Westport, CT 06881 <br /> Care of Melissa & Doug, LLC <br /> Location Code Alt Phone <br /> BOIS District Fax <br /> APN EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0043966 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name Alex Walton (Circle One) <br /> Account Balance as of 2/14/2018: $0.00 <br /> (Circle One) <br /> Transfer to Ac iv slnactve <br /> Progrom/Element and Description Record ID Employee 10 and Name Status New Owner? Delete <br /> 1920-HMBP-Common Materials PR0541435 EE0009817-ROBERT LOPEZ Active Y N AC D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,anrllor project specific,PHS/EHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as Ne OWNER an this form. I also certify that all operations will be performed in accoMancewith all applicable Ordinance Codes anclor Standards and State ander <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to b TRANSFERED: Amount Paid Date / / <br /> Payment Type(' Check Number Received (� <br /> EHD Staff: L Date x— !tel<8 Account out: Date rO---/ �// '6 <br /> COMMENTS: <br /> IDVOICe#: <br />