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Date run 2/18/2016 2:29:41PN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 2/18/2016 <br />Record Selection Criteria: Facility ID FA0009158 <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 OW0007158 Case Number: H01619 New Owner ID <br />Owner Name CARRIE, RON <br />Owner DBA PEGASUS PROMOTIONAL PRODUCTS <br />Owner Address 705 N SHORELINE BLVD <br />MOUNTAIN VIEW, CA 94043-3208 <br />Home Phone 650-965-2576 <br />Work/Business Phone Not Specified <br />Mailing Address 7a6-e1QH aE IN RI \ <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID FA0009158 10182469 <br />Facility Name PEGASUS PROMOTIONAL PRODUCTS <br />Location 1400 E SCOTTS AVE STE B <br />STOCKTON, CA 95205 <br />Phone 209-466-1531 <br />Mailing Address7 $e— <br />q <br />3-3208 '-/ w <br />Care of RON CARRIE / <br />Location Code 01 - STOCKTON Alt Phone <br />BOS District 001 - VILLAPUDUA, CARLOS j Fax <br />APN 15131043 j 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 AR0016158 New Account ID: <br />Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br />Account Name PEGASUS PROMOTIONAL PRODUCTS (Circle One) <br />Account Balance as of 2/18/2016: $290.00 <br />(Circle One) <br />Transfer to Active/Inactve <br />Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br />1921 - HMBP-Regular-Primary Location PR0511446 EE0000006 - HAZA SAEED Active Y N A I D <br />2220 - SM HW GEN <5 TONS/YR PR0513676 EE0000008 - LETITIA BRIGGS Inactive Y N A I D <br />2226 - CalARP PROGRAM PR0514534 EE0000000 - HAZ MAT SJC OES Inactive Y N A I D <br />2399 - UNIFIED PROGRAM FAC STATE SURCHARGE F PR0509158 EE0000000 - HAZ MAT SJC OES Inactive Y N A I D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARG PR0535985 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, 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: Date <br />Program Records to be TRANSFERED: * $25.00 = Amount Paid Date <br />Water System to be TRANSFERED: Amount Paid Date I / <br />Payment Type Check Number Received by <br />EHD Staff: Date / / Account out: Date / S-/16 <br />COMMENTS: <br />Invoice #: <br />C., C^Apw <br />