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Date run 2/24/2016 8:44:28AK SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report #5021 <br />Run by Pagel <br />Facility Information as of 2/24/2016 <br />Record Selection Criteria: Facility ID FA0023322 <br />OWNER FILE INFORMATION Number of facilities for this owner: 1 <br />Owner ID OW0021540 <br />Owner Name Tracey Anzar <br />Owner DBA <br />Owner Address <br />Home Phone Not Specified <br />Work/Business Phone 630-378-7398 <br />Mailing Address 1000 Remington Blvd <br />Bolingbrook, IL 60446 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID <br />FA0023322 10655518 <br />Facility Name <br />ULTA BEAUTY #314 <br />Location <br />5410 Pacific Ave <br />Stockton, CA 95207 <br />Phone <br />630-378-7398 x <br />Mailing Address <br />1000 Remington Blvd Suite 200 <br />Bolingbrook, IL 60446 <br />Care of <br />ULTA Beauty #314 <br />Location Code <br />BOS District <br />APN <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0042934 <br />Mail Invoices to Account <br />Account Name Nedra Allen <br />Account Balance as of 2/24/2016: $0.00 <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 />Alt Phone <br />Fax <br />EMail : <br />Mail Invoices to: <br />New Account ID: : <br />Owner / Facility / Account <br />(Circle One) <br />(Circle One) <br />Transfer to Active/Inaclve <br />Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br />1921 - HMBP-Reqular-Primary Location PR0540795 EE0000006 - HAZA SAEED Active Y N A I D <br />2220 - SM HW GEN <5 TONS/YR PR0540794 EE0000005 - FATINAH ZAREEF Active 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, PHS/EHD 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 = Amount Paid Date <br />Water System to be TRANSFERED: Amount Paid Date <br />Payment Type Check Number Received by <br />EHD Staff: U t Date /A/I" Account out: Date <br />COMMENTS: Invoice #: <br />C(1 A -11L-9 (vim► F ALA IL 11-1 aP,�S <br />n <br />