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FRun <br /> run 1/6/2015 11:58:19AM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> Report#5021 <br /> Facility Information as of 1/6/2015 Pagel <br /> Recont Selection Grieco: Facility ID FA0009084 <br /> Make changes/corrections In RED ink. 1 (y <br /> INFORMATION CHANGE(date) <br /> OW <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 <br /> SSN/Fed Tax I <br /> Owner ID OW0007084 Case Number: H01024 s New can ID . �— <br /> Owner Name �maJl .c e Fkadd�d Cd; <br /> Owner DBA 121TF-WAV CI A IFRc rnlr� a '�¢ tT <br /> Owner Address ?m--ET;An��� ( Zi ilkh <br /> QTUXT-Ol nn 9EP02 3'�" P!I^2' • A --L&LA V <br /> Home Phone C-� q 5 2'1 e) <br /> Not Specified p 09 _ 4- � ,y <br /> Work/Business Phone 209-464-4282 <br /> Mailing Address 700 E MARKET ST <br /> STOCKTON, CA 95202 <br /> Care of / p <br /> FACILITY FILE INFORMATION ` <br /> Facility lD/CERSID FA0009084 10182399 <br /> Facility Name RITEWAYCLEANE <br /> Location 700 E MARKET ST <br /> STOCKTON, CA 95202 <br /> Phone 209-464-4282 x <br /> Mailing Address 700 E MARKET ST <br /> STOCKTON, CA 95202 <br /> Care of �gggjgg-tptj9Nprj., S u J P;M CLA rG( '{�• 11 C. <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 001 -VILLAPLIDUA Fax <br /> APN 14922012 Entail: m1 Ch•e 4 ryjq , (Qyi1 <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name S 4 L it 11A A. L <br /> Title <br /> Day Phone HSo/. 2 O — Z— <br /> Night Phone CQ( __ Zd -' - 4$ —,�-G(-n-Z <br /> ACCOUNTS RECEIVABLE FILE INFORMATION l <br /> Account ID AR0016084 New Account ID: <br /> Maillnvoicesto Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name RITEWAY CLEANERS (chcleOne) <br /> Account Balance as of 1/6/2015: $0.00 <br /> (Cimle One) <br /> Program/Element and DescTranderto ActivellnacNe <br /> ription Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Reqular-Primary Location PRO519370 EE0009817-ROBERT LOPEZ Active Y N I D <br /> 2220-SM HW GEN<5 TONS/YR PRO513629 EE0009488-JEFFREY WONG Active Y N 1 D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PRO511372 EE0000000-HAZ MAT SJC OES'�- na Ive Y N I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE FI PR0509084 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGI PRO532559 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andror protect specRic,PHS(EHD hourly charges associated with this faciNy <br /> or activily will be billed to the party deridetl as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and State andor <br /> Federal Laws. ` A n <br /> APPLICANTS SIGNATURE: /Zz % Date <br /> Program Records to be TRANSFERED: 5.00= Amount Paid Date <br /> Water System to RA F ED: Amount Paid Date <br /> Payment Type Check Number Receiv�ed2by / 1 <br /> REHS: Date_/ / Account out: r Date <br /> COMMENTS: I -- <br />