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Date run 7/17/2017 1:34:06PW SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 7/17/2017 <br />Record Selection Criteria: Facility ID FA0023224 <br />OWNER FILE INFORMATION Number of facilities for this owner <br />Owner ID <br />OW0021372 <br />Owner Name <br />Lumber Liquidators, Inc. <br />Owner DBA <br />963 W March Ln <br />OwnerAddress <br />3000 JOHN DEERE RD <br />Phone <br />TOANO, VA 23168 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />757-946-0087 <br />Mailing Address <br />3000 John Deere Rd <br />Location Code <br />Toano, VA 23168 <br />Care of <br />Fax _ <br />FACILITY FILE INFORMATION <br />Make changesicorrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />SSN / Fed Tax ID <br />New Owner ID : <br />Facility ID / CERS ID <br />FA0023224 10651183 <br />Facility Name <br />Lumber Liquidators Store 1358 <br />Location <br />963 W March Ln <br />Stockton, CA 95207 <br />Phone <br />209-337-3704 x <br />Mailing Address <br />3000 John Deere Rd <br />Toano, VA 23168 <br />Care of <br />Lumber Liquidators, Inc. <br />Location Code <br />Alt Phone <br />BOS District <br />Fax _ <br />APN <br />EMail : <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0042707 New Account ID: <br />Mail Invoices to Account Mail Invoices to: Owner / <br />Account Name Catherine Hoffman <br />Account Balance as of 7/17/2017: $0.00 <br />Facility / Account <br />(Circle One) <br />(Circle One) <br />Transferto Active/Inactve <br />Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br />1921 - HMBP-Regular-Primary Location PR0540605 EE0008709 - JAMIE LIMA Active Y N A0 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 TyCheckCheck Number Received by <br />EHD Staff: (' Date �/1�/J2 Account out: 6z= Date _�/ /17 <br />COMMENTS: <br />Invoice #: <br />rVaA& <br />