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Date run 2/16/2017 10:27:52AI SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 2/16/2017 <br />Record Selection Criteria: Facility ID FA0023864 <br />OWNER FILE INFORMATION Number of facilities for this owner.- 1 <br />Owner ID OW0022294 <br />Owner Name Medline Industries <br />Owner DBA <br />Owner Address <br />Home Phone Not Specified <br />Work/Business Phone 800-633-5463 <br />Mailing Address 3 Lakes Drive <br />Northfield, IL 60093 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID <br />FA0023864 10726192 <br />Facility Name <br />Medline Industries <br />Location <br />5701 Promontory Pkwy <br />Tracy, CA 95377 <br />Phone <br />209-836-7026 x <br />Mailing Address <br />5701 Promontory Parkway <br />Tracy, CA 95377 <br />Care of <br />Medline Industries <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 <br />AR0044237 <br />Mail Invoices to <br />Account <br />Account Name <br />David Solis <br />Account Balance as of 2/16/2017: <br />$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 />New Account ID: : <br />Mail Invoices to: Owner / Facility / Account <br />(Circle One) <br />(Circle One) <br />Transfer to Active/]naclve <br />Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br />1921 - HMBP-Regular-Primary Location PR0541643 EE0000016 - BETTY HO 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 with all applicable Ordinance Codes and/or Standards and State andror <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 Type Check Number Received by <br />EHD Staff: Date _/�a Account out: Date / / 7 <br />COMMENTS: <br />#: <br />C TC -9 N T_ AC, t L tri Q a-oG, (LPfA Invoice <br />0 yp S 05 � o r1 Zj �t t '1 CS S <br />