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Date run 11/30/2015 1:19:47P SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 11/30/2015 <br />Record Selection Criteria: Facility ID FA0023224 <br />OWNER FILE INFORMATION Number of facilities for this owner: 1 <br />Owner ID OW0021372 <br />Owner Name Lumber Liquidators, Inc. <br />Owner DBA <br />Owner Address <br />Home Phone Not Specified <br />Work/Business Phone 757-946-0087 <br />Mailing Address 3000 John Deere Rd <br />Toano, VA 23168 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID FA0023224 10651183 <br />Facility Name 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 />BOS District <br />APN <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 <br />Mail Invoices to Account <br />Account Name Catherine Hoffman <br />Account Balance as of 11/30/2015: $0.00 <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />SSN /Fed Tax ID <br />New Owner ID : <br />Alt Phone <br />Fax <br />EMail : <br />Mail Invoices to: <br />New Account ID: : <br />Owner / Facility / Account <br />(Circle One) <br />(Circle One) <br />Transfer to Active/Inactve <br />Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br />1921 - HMBP-Reqular-Primary Location PR0540605 EE0000006 - HAZA SAEED Active 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, 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 withal[ applicable Ordinance Codes and/or Standards and State and/or <br />Federal Laws. <br />APPLICANT'S SIGNATURE: <br />Program Records to be TRANSFERED: <br />Water System to be TRANSFERED: <br />Payment Type Check Number <br />FHD Staff: <br />COMMENTS: <br />96kkf14— 04A) <br />Date / 1 <br />$25.00 = Amount Paid Date <br />Amount Paid Date <br />Date <br />Received by <br />Account out: f,5 Date <br />Invoice #: <br />