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Date run 1/8/2016 8:26:58AM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 1/8/2016 <br /> Record Selection Criteria: Facility ID FA0002093 <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: 11 SSN/Fed Tax ID <br /> Owner ID OW0000531 New Owner ID <br /> Owner Name Dolgen California, LLC <br /> Owner DBA DOLLAR GENERAL <br /> Owner Address 100 MISSION RIDGE <br /> GOODLETTSVILLE, TN 370722171 <br /> Home Phone 615-8554781 <br /> Work/Business Phone 615-855-4024 <br /> Mailing Address 100 Mission Ridge <br /> Goodlettsville, TN 37072 <br /> Care of TAX DEPT <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0002093 10180865 <br /> Facility Name DOLLAR GENERAL#13632 <br /> Location 2907 E WATERLOO RD <br /> STOCKTON, CA 95205 <br /> Phone 209-800-8944 x <br /> Mailing Address 100 MISSION RIDGE <br /> GOODLETTSVILLE, TN 37072-2171 <br /> Care of DOLLAR GENERAL#13632 <br /> Location Code 99- UNINCORPORATED A Alt Phone <br /> BOS District 001 -VILLAPUDUA, CARLOS Fax <br /> APN 11928001 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name ATTN: TAX DEPT <br /> Title <br /> Day Phone 615-855-4781 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0008569 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name ERIC VOYLES (Circle One) <br /> Account Balance as of 1/8/2016: $0.00 <br /> (Circle One) <br /> Transfer to Activellnactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1618-RETAIL MKT>2000 SO FT (PREPKGD/LTD PRE PRO161907 EE0009488-JEFFREY WONG Active Y N A I D <br /> 1698-SPECIAL EVENT PRO537164 EE0009488-JEFFREY WONG Active Y N A6 D <br /> 1921 -HMBP-Regular-Primary Location PRO540010 EE0000006-HAZA SAEED Active Y N A( II D <br /> 2220-SM HW GEN<5 TONS/YR PR0537154 EE0001421 -STACY RIVERA Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGI PR0537155 EE0009488-JEFFREY WONG Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the underaigned owner,operator or agent of same,acknowledge that all ske,ani project specific,PHS/EHD hourly charges associated with this facility or: <br /> be billed to the party identifed as the OWNER on this form. I also certify that all operations will be pertonned in accordance with all applicable Ordinance Codes anclor Standards and State andor 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 <br /> Payment Type Check Number Received by 4'- <br /> EHD Staff. ��-�,. Date / / Account out: Date f / / / `' <br /> COMMENTS: n` ` \ _ <br /> `- �`s3ty�_ N,o�2 ` 'e - SPc;\'•'�`( -�S Invoice#: <br />