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Date run 2/27/2015 8:49:27AN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 2/27/2015 <br /> Record Selection Criteria: Facility ID FA0022800 <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 OW0020687 New Owner ID <br /> Owner Name Gary Alegre <br /> Owner DBA <br /> Owner Address <br /> Home Phone Not Specified <br /> Work/Business Phone 209-932-0495 <br /> Mailing Address 743 W. Anderson St. <br /> Stockton, CA 95206 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0022800 10619341 <br /> Facility Name Blue Mountain Minerals <br /> Location 1001 Humphrey S Dr <br /> Stockton, CA 95203 <br /> Phone 209-932-0495 x <br /> Mailing Address 743 W. Anderson St. <br /> Stockton, CA 95206 <br /> Care of Michael Vilarino <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 AR0041814 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name Michael Vllarino <br /> Account Balance as of 2/27/2015: $0.00 (Circle One) <br /> (Circle One) <br /> Program/Element and Description Record ID Employee ID and NameTransfer to Active/Inactve <br /> 1921 -HMBP-Reqular-Primary Location PR0539856 EE0009817-ROBERT LOPEZ Status New Owner? Delete <br /> 2220-SM HW GEN<5 TONS/YR PR0539855 EE0001421 -STACY RIVERA ActActive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,ancvor project specific,PHS/EHDI hourly charges assocve Y iated 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 ancvor <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: <br /> Date <br /> Program Records to be TRANSFERED: "$25.00= Amount Paid <br /> Water System to be TRANSFERED: Date <br /> Amount Paid Date <br /> Payment Type Check Number <br /> REHS: Received by <br /> Date < Account out: Uj Date <br /> COMMENTS: <br /> G P,2 G&AV-, <br /> S \1A <br /> 3 L w c i�F S . " (r <br />