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i <br /> Date win 5/1/2014 3:39:12PM Report#5021 <br /> SAN J IN COUNTY ENVIRONMENTAL HEA DEPARTMENT <br /> RIC by <br /> Facility Information as of 5/1/2014 Pagel <br /> Record Selection Criteria: Facility ID FA0009403 <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 OW0007403 Case Number: H03751 New Owner ID <br /> Owner Name HD SUPPLY WATERWORKS LTD <br /> Owner DBA HD SUPPLY WATERWORKS LTD <br /> Owner Address 1615 S STOCKTON ST <br /> LODI, CA 95240 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-334-9768 <br /> Mailing Address 1.645-S STOCKTON ST <br /> LODI, CA 95240 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0009403 10,182,659 <br /> Facility Name HD SUPPLY WATERWORKS LTD <br /> Location 1615 S STOCKTON ST <br /> LODI, CA 95240 <br /> Phone 209-334-9768 I ^ <br /> Mailing Address JI S.YZ SICCi <br /> LODI, CA 95240 <br /> Care of <br /> Location Code 02- LODI Alt Phone <br /> BOS District 004-VOGEL, KEN Fax <br /> APN 06205011 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0016403 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name HD SUPPLY WATERWORKS LTD (Circle One) <br /> Account Balance as of 5/1/2014: $0.00 <br /> (Circle One) <br /> Tansrerto Activellnaclve <br /> ProgaMElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PR0520993 EE0008709-JAMIE DE LA ROSA Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PRO513818 EE0001422-ARIS CACAPIT Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PR0511691 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PRO509403 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0533739 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,anNor project specific,PHS/EHD hourly charges associated with this facility <br /> or activity will be billed!to Me party identified as the OWNER on this form. I else certify that all operations will be performed in accordance with all applicable Ordinance Codes anNor Standards and State anther <br /> Federal Laws. <br /> APPLICANTS 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 a Check Number Receive <br /> REHS: Date Date <br /> COMMENTS: <br />