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Date mn 3/17/2014 11:53:21AI SAN JCOUIN COUNTY ENVIRONMENTAL HEAS DEPARTMENT Report #5021 <br />Rrn b} � < Pagel <br />Facility Information as of 3/17/2014 <br />Record Selection Criteria: Facility ID FA0018143 <br />OWNER FILE INFORMATION <br />Owner ID <br />OW0014886 <br />Owner Name <br />HD SUPPLY INC / CROWN BOLT <br />Owner DBA <br />HD SUPPLY DISTRIBUTION SERVICE <br />Owner Address <br />501 W CHURCH ST <br />ORLANDO, FL 22385 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />770-852-9000 <br />Mailing Address <br />501 W CHURCH ST <br />ORLANDO, FL 22385 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility lD/CERS ID FA0018143 10186781 <br />Facility Name HD SUPPLY DISTRIBUTION SERV CBO <br />Location 2055 INDUSTRIAL DR <br />STOCKTON, CA 95206 <br />Phone 209-234-8930 xO <br />Mailing Address 501 W CHURCH ST <br />ORLANDO, FL 22385 <br />Care of <br />Location Code 01 - STOCKTON <br />BOB District 001 - VILLAPUDUA <br />APN 17733020 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Make changes/corrections In RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />SSN /Fed Tax ID <br />New Owner ID : <br />Account ID AR0031913 <br />Mail Invoices to Owner Mail Invoices to: <br />Account Name HD SUPPLY INC / CROWN BOLT <br />Account Balance as of 3/17/2014: $638.00 <br />ProgramlElement and Description Record ID Employee ID and Name <br />New Account ID: : <br />Owner / Facility / Account <br />(Circle One) <br />(Circle One) <br />Transferto Activellnachre <br />Status New Owner? Delete <br />1921 - HMBP-Regular-Primary Location PRO526786 EE0009817 - ROBERT LOPEZ Active Y N A I D <br />2220 - SM HW GEN <5 TONS/YR PR0538428 EE0001421 - STACY RIVERA Active Y N A I D <br />4740 - WASTE TIRE SITE - EXEMPT PR0535050 EE0002620 - ALFONSO ARAMBULA Inactive Y N A I D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARG PRO533466 Inactive Y N A 1 D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, adnowledge that all site, anclor project specific, PHS/EHD hourly charges associated with this facility <br />or activity will be billed to the party identified as the OWNER on this form l also certify that all operations will be performed in accordance with all applicable Ordinance Codes and'or Standards and State anNar <br />Federal Laws. <br />APPLICANT'S SIGNATURE: See_ A ` K� —i—rv-tiD/C/ P—, Date <br />Program Records to be TRANSFERED: <br />Water System to be TRANSFERED: <br />Payment Type Check Number <br />REHS: <br />COMMENTS: <br />" $25.00 = <br />Date <br />Amount Paid Date <br />Amount Paid Date <br />Received b <br />Account out: <br />