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Date run 5/22/2014 1:21:49PK SAN JUIN COUNTY ENVIRONMENTAL HEA-M&DEPARTMENT Report/5021 <br /> Run by Pagel <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 HOME DEPOT USA 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 PO BOX 105465 <br /> ATLANTA, GA 30348 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0010345 10140205 <br /> Facility Name HOME DEPOT#662 <br /> Location 3818 E HAMMER LN <br /> STOCKTON, CA 95212 <br /> Phone 209-476-9600 <br /> Mailing Address PO BOX 19157 <br /> IRVINE, C 23 <br /> Care of M002RUHSTALLER, <br /> YOUNG LLP <br /> Location CodeCKTON Alt Phone <br /> BOS Dis LARRY Fax <br /> APN 13003002 EMaiI: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID <br /> to AR001 <br /> itillF ,� New Account ID: <br /> Mail Invoices to�j(jty--y�✓y//T�_ Mail Invoices to: Owner / Facility / Account <br /> Account Name HOME DEPO #662 (ClmleOne) <br /> Account Balance as of 5/22/2014: $0.00 <br /> (Circle One) <br /> Transfer to Active9nacNe <br /> Program/Eurrumt and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1620-RETAIL MKT 26-300 SO FT(INCIDENTAL FOOD: PR0526579 EE0001084-STEPHANIE RAMIREZ Active Y N A I D <br /> 1921 -HMBP-Regular-Primary Location PR0520253 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 EEOo000OO-HAZ MAT SJC OES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO534193 Inactivc 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 PHStEHD hourly charges associated with this facility <br /> or activity will be billetl to the party identified as the OWNER on this form. Ialso certify that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and State andor <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: Dale <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Check Number Receiy <br /> REHS: Date / / Account out: M Date <br /> COMMENTS: \n✓ <br />