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FRunby <br /> 12/20/2016 4:42:37F SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> Report#5021 <br /> Facility Information as of 1212012016 Pagel <br /> ction Criteria: Facility ID FA0023799 <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 OW0022162 New Owner ID <br /> Owner Name American Biodiesel Inc <br /> Owner DBA <br /> Owner Address <br /> Home Phone Not Specified <br /> Work/Business Phone 760-942-9306 <br /> Mailing Address PO Box 23-4249 <br /> Encinitas, CA 92023 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0023799 10717633 <br /> Facility Name Community Fuels Terminal <br /> Location 910 Gilmore Ave <br /> Stockton, CA 95203 <br /> Phone 209-466-4823 x <br /> Mailing Address PO BOX 23-4249 <br /> Encinitas, CA 92023 <br /> Care of American Biodiesel Inc <br /> Location Code Alt Phone <br /> BOS 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 AR0044074 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility I Account <br /> Account Name Chris Stowe (Circle one) <br /> Account Balance as of 12/20/2016: $0.00 <br /> (Circle One} <br /> Transfer to Active/inactve <br /> ProgramlElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Req ular-Primary Location PR0541515 EF0009817-ROBERT LOPEZ Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PRO541514 EE0001421 -STACY RIVERA Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEOGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andlor project specific„PHSlFHD 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 andlor <br /> Federal Laws <br /> APPLICANT'S SIGNATURE Date / I <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date 1 I <br /> Water System to be TRANSFERED: Amount Paid Date I I <br /> Payment Type Number Received bv <br /> EHD Staff E 6,4 DateL2- I leo Account out Date a<+�-1 1 7�✓ <br /> COMMENTS <br /> `Z�� b Invoice#, <br /> D -7 <br />