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4 <br /> Dale run 121612012 2:12:21PR SAN JOIN COUNTY ENVIRONMENTAL HEA JO DEPARTMENT 1#5021 <br /> Run by Pagel <br /> Facility Information as of 12/6/2012 <br /> Record Selection Criteria: Facility ID FA0018025 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0001634 New Owner ID <br /> Owner Name NOR CAL BEVERAGE <br /> Owner DBA NOR-CAL BEVERAGE CO INC <br /> Owner Address 175 ENTERPRISE CT C <br /> GALT, CA 956328795 <br /> Home Phone Not Specified <br /> Work/Business Phone 916-372-0600 <br /> Mailing Address 175 ENTERPRISE CT#C <br /> GALT, CA 956328795 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0018025 <br /> Facility Name NOR CAL BEVERAGE <br /> Location 3033 TRANSWORLD DR <br /> STOCKTON, CA 95206 <br /> Phone 209-983-8020 <br /> Mailing Address 175 ENTERPRISE CT#C <br /> GALT, CA 956328795 <br /> Care of NOR CAL BEVERAGE <br /> Location Code 01 - STOCKTON Alt Phone <br /> BOS District 001 -VILLAPUDUA Fax <br /> APN 17928019 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name NOR CAL BEVERAGE <br /> Title <br /> Day Phone 209-983-8020 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0031669 New Account ID: <br /> Mail Invoices to Facility 'Mail Invoices to: Owner I Facility I Account <br /> Account Name NOR CAL BEVERAGE {Circle One) <br /> Account Balance as of 12/6/2012: $0.00 <br /> (Circle One) <br /> Transfer to ActivefInaci <br /> PrograrrJElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1644-VENDING MACHINES PRO526627 EE0006213-VIDAL PEDRAZA Inactive Y N A I D <br /> 1921 -HMBP-Regular-Primary Location PRO527149 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,PHSIEHD 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 anti Standards and State andror <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date I 1 <br /> Program Records to be TRANSFERED: $25.00= Amount Paid Date ! 1 <br /> Water System to be TRANSFERED: Amount Paid Date ! 1 <br /> Payment Type Check Number Received by <br /> RENS: Date 1 I Account out: Date 1 1 <br /> COMMENTS' <br />