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Date run 3/1/2016 11:04:31AM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report;15021 <br /> Run by <br /> Facility Information as of 3/1/2016 Pagel <br /> Record Selection Criteria: Facility ID FA0019340 <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: 3 SSN/Fed Tax ID <br /> Owner ID OW0014589 New Owner ID <br /> Owner Name SANGUINETTI INVESTMENTS LLC <br /> Owner DBA <br /> Owner Address 18180 FORMON CT <br /> LINDEN, CA 95236 <br /> Home Phone 209-607-9229 <br /> Work/Business Phone 209-607-9229 <br /> Mailing Address 18638 E Copperopolis Rd <br /> Linden, CA 95236 <br /> Care of SANGUINETTI JR, RON J <br /> FACILITY FILE INFORMATION <br /> Facility ID I CERS 10 FA0019340 10187221 <br /> Facility Name FARMINGTON CIRCLE K <br /> Location 4391 S ESCALON BELLOTA RD <br /> FARMINGTON, CA 95230 <br /> Phone 209-607-9229 <br /> Mailing Address 18638 E COPPEROPOLIS RD <br /> LINDEN, CA 95236 e„ / <br /> Care of SANGUINETTI INVESTMENTS LLC <br /> Location Code 99- UNINCORPORATED P Alt Phone <br /> BOS District 004-WINN, CHARLES Fax <br /> APN 18713006 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name TON SSANGUINETTI <br /> Title MANAGING MEMBER <br /> Day Phone 209-607-9229 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0034369 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name FARMINGTON CIRCLE K (Circle One) <br /> Account Balance as of 3/1/2016: $0.00 <br /> (Circle One) <br /> Transfer to ActiveflnacNe <br /> PrograMElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2351 -UST FACILITY-2481 COMPLIANT PR0528866 EE0009488-JEFFREY WONG Inactive Y N A I D <br /> 2832-AST FAC 10 K-</=100 K GAL CUMULATIVE PR0530554 EE0000027-CINDY VO Active Y N A� i D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0532086 Inactive Y N A --t- D <br /> L <br /> ING and COMPLIANCE ACKNOWLEDGEMENT. I,the undersigned owner,operator or agent of same,acknowledge that all site,andor project specific,PHSEHD hourly charges associatetl with this facility <br /> civitywllbebed tothe party identified as the OWNER on this form I also certify that all operations will be,performed in accordance with all applicable Ordinance Codes ander Standards antl State andseral Laws. 0 �� <br /> itc full e add/� _ � is 4�y1�'q S es'?4 &,77 <br /> APPLICANTS SIGNATURE: �If�-� a' }''V ly •l 9 g g <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 / I Account out: Date 3 / 4/ <br /> COMMENTS: /) <br /> J/T/(Jrv,Jp Invoice#: <br />