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Date run 9/1/2015 3:46:54PM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 9/1/2015 <br />Record Selection Criteria: Facility ID FA0002222 <br />OWNER FILE INFORMATION Number of facilities for this owner: 10 <br />Owner ID <br />OW0000531 <br />Owner Name <br />DOLGEN CALIFORNIA, LLC <br />Owner DBA <br />DOLLAR GENERAL <br />Owner Address <br />100 MISSION RIDGE <br />Day Phone <br />GOODLETTSVILLE, TN 370722171 <br />Home Phone <br />615-855-4781 <br />Work/Business Phone <br />615-855-4024 <br />Mailing Address <br />100 MISSION RIDGE <br />Mail Invoices to Account <br />GOODLETTSVILLE, TN 37072 <br />Care of <br />ATTN: TAX DEPT <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID FA0002222 10413040 <br />Facility Name Dollar General #13593 <br />Location 4232 E Main St <br />Stockton, CA 95215 <br />Phone 209-800-8822 x <br />Mailing Address 100 MISSION RIDGE <br />GOODLETTSVILLE, TN 37072 <br />Care of DOLLAR GENERAL #13593 <br />Location Code 99 - UNINCORPORATED P <br />Bos District 002 - MILLER, KATHERINE <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 />Fax <br />APN <br />EMail : <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name TINA HONEYCUTT <br />Title TAX ADMINISTRATOR <br />Day Phone <br />Night Phone 615-855-4781 <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0002233 <br />New Account ID: <br />Mail Invoices to Account <br />Mail Invoices to: Owner / Facility / Account <br />Account Name ERIC VOYLES <br />(Circle One) <br />Account Balance as of 9/1/2015: $-231.00 <br />(Circle One) <br />Transfer to Active/lnactve <br />Program/Element and Description Record ID <br />Employee ID and Name Status New Owner? Delete <br />1618 - RETAIL MKT >2000 SQ FT (PREPKGD / LTD PRE PRO161585 <br />EE0008999 - LEYNA HUYNH Active Y N A I D <br />1698 - SPECIAL EVENT PR0537166 <br />EE0008999 - LEYNA HUYNH Active Y N A I D <br />1921 - HMBP-Regular-Primary Location PR0539167 <br />EE0000006 - HAZA SAEED Active Y N AI/ D <br />2220 - SM HW GEN <5 TONS/YR PR0537835 <br />EE0001421 - STACY RIVERA Active Y N A I D <br />3116 - STORMWATER INSPECTION - FOOD PR0522926 <br />EE0006213 - VIDAL PEDRAZA Inactive Y N A I D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, and/or project specific, PHSIEHD 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 and/or <br />Federal Laws. <br />APPLICANT'S SIGNATURE: <br />Date <br />Program Records to be TRANSFERED: ' $25.00 = <br />Amount Paid Date <br />Water System to be TRANSFERED: <br />Amount Paid Date <br />Payment Type Check Number <br />Received by <br />EHD Staff: Date `\ <br />Account out: Date /�/ / <br />COMMENTS: <br />111VOICe #: <br />�'Zo -4.c, <br />� <br />