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Report#5021 <br /> Date run 5/22/ 14 1:23:31Pk SAN JUIN COUNTY ENVIRONMENTAL HEAWA DEPARTMENT Pagel <br /> Run by <br /> Facility Information as of 5/22/2014 <br /> Record Selection Criteria: Facility ID FA0010345 <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: 6 SSN/Fed Tax ID <br /> Owner ID OW0008345 Case Number: H07812 New Owner ID <br /> Owner Name THE HOME DEPOT U.S.A., INC. <br /> Owner DBA HOME DEPOT <br /> Owner Address 2455 PACES FERRY RD <br /> ATLANTA, GA 30339 <br /> Home Phone Not Specified <br /> Work/Business Phone 770-433-8211 <br /> Mailing Address 2455 PACES FERRY ROAD, C-19 <br /> ATLANTA, GA 30339 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0010345 10140205 <br /> Facility Name THE HOME DEPOT STORE#0662 <br /> Location 3818 E Hammer Ln <br /> Stockton, CA 95212 <br /> Phone 209-476-9600 x <br /> Mailing Address 3818 E HAM ER LN <br /> STOCKTION, CA 95212 <br /> Care of T HOME DEPOT STORE#0662 <br /> Location Code 01 - STOCKTON Alt Phone <br /> Bos District 002 - RUHSTALLER, LARRY 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 /> AccountlD AR0017345 New Account ID: <br /> Mail Invoices toF�,,, ,; DEPMail Invoices to: Owner / Facility / Account <br /> Account Name T E1 HO OT STORE#0662 (Circle One) <br /> Account Balance as of 5/22/2014: $0.00 <br /> (Circle One) <br /> Transfer to ActivelilacNe <br /> Progra"Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1620-RETAIL MKT 26-300 SO FT(INCIDENTAL FOOD; PRO526579 EE0001084-STEPHANIE RAMIREZ Active Y N A I D <br /> 1921 -HMBP-Regular-Primary Location PRO520253 EE0006044-LOWELL ALLEN Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PR0517913 EE0005642-MICHELLE HENRY Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PR0512633 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PR0510345 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO534193 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andor project specific,PHSrEHD 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 appllrable Ordinance Codes andor Standards and State ands <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date / I <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> REHS: <br /> Payment Type Check Number Date / / Account out: Re a by 11L Zk- Date / / V <br /> COMMENTS: <br /> c-A Lo lj .�dc 2O lel n <br />