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Date run 5/7/2018 4:28:43PM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 5/7/2018 <br />Record Selection Criteria: Facility ID FA0018755 <br />OWNER FILE INFORMATION Number of facilities for this owner : 1 <br />Owner ID OW0015422 <br />Owner Name �+S Ait 6trridlitYen+ng Distributors, LLC <br />Owner DBA "13tSTi Jl TORS <br />Owner Address-J6S6e-G44ESTN.T-8F <br />1748 <br />Home Phone 62"- 5-4--45&-7- <br />Work/Business Phone 6-26--8t4--450-7 <br />Mailing Address 16900-Chestnut-Street-- <br />-Cnus - <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID/CERS ID <br />FA0018755 10186973 <br />Facility Name <br />Saveco Distributors <br />Location <br />2826 N TEEPEE DR STE 103 <br />STOCKTON, CA 95205 <br />Phone <br />209-466-1129 x <br />Mailing Address <br />2826 N TEEPEE DR STE 103 <br />STOCKTON, CA 95205 <br />Care of <br />Keith Tackett <br />Location Code <br />Bos District <br />001 - VILLAPUDUA, CARLOS <br />APN <br />13208002 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0033300 <br />Mail Invoices to Account <br />Account Name L1 Ajf-Conditioning-Di <br />Account Balance as of 5/7/2018: $0.00 <br />Make changestcorrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />SSN / Fed Tax ID <br />New Owner ID <br />G O %L <br />✓SSSS <br />Alt Phone <br />Fax <br />EMail : <br />V—C .) �A i <br />08— <br />New Account ID: : <br />Mail Invoices to: Owner / Facility / Account <br />(Cir a One) <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-Reqular-Primary Location PR0527671 EE0009817 - ROBERT LOPEZ Active Y N A I D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARGI PR0532053 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: <br />Date <br />Program Records to be TRANSFERED: ' $25.00 = Amount Paid Date <br />Water System to be TRANSFERED: Amount Paid Date <br />Payment Typ Check Number Received by <br />EHD Staff: L - Date Account out: Date <br />COMMENTS: <br />Invoice #: <br />