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Date nun 10/25/2013 10:06:02/ SAN JO)JIN COUNTY ENVIRONMENTAL HEA DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 10/25/2013 <br /> Record Selection 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 lD 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 lD/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 /> BOIS District Fax <br /> APN 09614023 EMail: <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 Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name CVS/PHARMACY#9916 (Circle One) <br /> Account Balance as of 10/25/2013: $420.00 <br /> (Circle One) <br /> Transfer to ActiveAnactve <br /> Progran-Element and Description Record ID Employee ID 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 /> 1921 -HMBP-Regular-Primary Location PRO538038 EE0006044-LOWELL ALLEN Inactive Y N ® 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 Net all site,ander project spec,PHS/EHO 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 andor Standards and State ardor <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: Date / I <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 Re! iv y <br /> REHS: Date / /L Account out: uC Date <br /> COMMEN <br /> -A-er7✓4r"!G A7c .C'CycS SUSFf/TY/I-t /✓o77F>C/j-T70,n/ (�vc7t/ ro (�ciSii✓C—IJ` �Sdc^.� <br /> /Zc/a,, rR-acC 42u.a,nrT7 rr c'7 —,vie e.�l-r7��c S. . <br />