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Date run 4/27/2016 8:59:05AA SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 4/27/2016 <br /> Record Selection Criteria: Facility ID FA0012655 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID <br /> Owner ID OW0009852 New Owner ID <br /> Owner Name BONADONNAS ASPHALT REPAIR <br /> Owner DBA <br /> Owner Address 3883 S EL DORADO ST <br /> STOCKTON, CA 95206 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-982-1804 <br /> Mailing Address PO BOX 6377 <br /> STOCKTON, CA 95206 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0012655 10184313 <br /> Facility Name BONADONNAS ASPHALT REPAIR <br /> Location 3883 S EL DORADO ST <br /> STOCKTON, CA 95206 <br /> Phone 209-982-1804 x <br /> Mailing Address PO BOX 6377 <br /> STOCKTON, CA 95206-0377 <br /> Care of Bonadonna's Asphalt Repair Inc <br /> Location Code 01 - STOCKTON Alt Phone <br /> BOS District 001 -VILLAPUDUA, CARLOS Fax <br /> APN 17525056 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name DAVID BONADONNA <br /> Title PRESIDENT <br /> Day Phone 209-982-1804 <br /> Night Phone 209-993-3159 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0020956 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name BONADO ASPHALT REPAIR (Circle One) <br /> Account Balance as of 4/27/201 : $620.5 —� M1Dvt _�o R2--7 S. Cl _L:>O y2zS <br /> (Circle One) <br /> Transfer to Active/Inaclve <br /> Program/Element and Description ORecord ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PR0530820 EE0009817-ROBERT LOPEZ Active Y N A D <br /> 2220-SM HW GEN<5 TONS/YR PR0538939 EE0001421 -STACY RIVERA Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PR0516519 EE0000451 -STEVE SASSON Inactive Y N A D <br /> 2831 -AST FAC >/= 1,320-<10 K GAL CUMULATIVE PR0516518 EE0001421 -STACY RIVERA Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO532976 Inactive 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 and/or <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: "$25.00= Amount Paid Date <br /> Water System to be TRANSFERE - Amount Paid Date <br /> Payment Ty a eck Number Received b ,I <br /> EHD Staff: Date /a� / Account out: Date s/ <br /> COMMENTS: Invoice#t: <br />