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I <br /> Dat;on 10/2/2013 10:51:19AI SAN J( IUIN COUNTY ENVIRONMENTAL HEAiiial DEPARTMENT v <br /> Run _� Repos#5021 <br /> Facility Information as of 10/2/2013 Pagel <br /> Rewelection Criteria: Facility ID FA0002791 <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 OW0016236 New Owner ID <br /> Owner Name LONGS DRUG STORES CALIF LLC <br /> Owner DBA CVS/PHARMACY <br /> Owner Address ONE CVS DR <br /> WOONSOCKET, RI 02895 <br /> Home Phone 401-770-3315 <br /> Work/Business Phone 401-652-9170 <br /> Mailing Address ONE CVS DRIVE MAIL DROP 23062A <br /> WOONSOCKET, RI 02895 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID I CERS ID FA0002791 10,180,995 <br /> Facility Name CVS/PHARMACY#9916 <br /> Location 5070 WEST LN <br /> STOCKTON, CA 95210 <br /> Phone 209-472-9682 <br /> Mailing Address ONE CVS DR MAIL DROP 23062A <br /> WOONSOCKET, RI 02895 <br /> Care of LICENSING DEPT/RUTH PAREDES <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District Fax <br /> APN 09614023 Eli <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name LICENSING DEPT/DURAND, DIANNE <br /> Title <br /> Day Phone 401-770-3315 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0004477 New Account ID: <br /> Mail lnvoicesto Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name CVS/PHARMACY#9916 (Circle One) <br /> Account Balance as of 10/2/2013: $0.00 <br /> (Circle One) <br /> Transfer to Actitennactve <br /> Progra"Element and Description Record ID Employee 10 and Name Status New Owner? Delete <br /> 1618-RETAIL MKT>2000 SO FT (PREPKGD/LTD PRE PRO167533 EE0001084-STEPHANIE RAMIREZ Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PR0531207 EE0005642-MICHELLE HENRY Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO532507 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that tel site,andor project specific,PHS/EHD hourly chargee 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 andor Standards and State ands <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 <br /> Payment Type Check Number Receiv y <br /> REHS: Date / / / /3 Account out: , Date <br /> COMMENTS: <br /> (Z �� � Lq <br />