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'Date om 2/27/2015 8:49:27An SAN X( ��UfN COUNTY ENVIRONMENTAL HEP `p'DEPARTMENT Report#5021 <br /> Run by V 1/ Pagel <br /> Facility Information as of 2/27/2015 <br /> Record Selection Criteria: Facility ID FA0022800 <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 10 : <br /> Owner lD OW0020687 New Owner ID <br /> Owner Name Gary Alegre <br /> Owner DBA <br /> Owner Address <br /> Home Phone Not Specified <br /> Work/Business Phone 209-932-0495 <br /> Mailing Address 743 W. Anderson St. <br /> Stockton, CA 95206 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0022800 10619341 <br /> Facility Name Blue Mountain Minerals <br /> Location 1001 Humphrey S Dr <br /> Stockton, CA 95203 <br /> Phone 209-932-0495 x <br /> Mailing Address 743 W. Anderson St. <br /> Stockton, CA 95206 <br /> Care of Michael Vilarino <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 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 AR0041814 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name Michael Vllarino (Circle One) <br /> Account Balance as of 2/27/2015: $0.00 <br /> (Circle One) <br /> Transfer to Acgvelinadve <br /> PrograMElement and Description Record ID Employee ID and Name Status New Career? Delete <br /> 1921 -HMBP-Reqular-Primary Location PR0539856 EE0009817-ROBERT LOPEZ Active Y N A I D <br /> 2220-SM HW GEN<5 TONSNR PRO639855 EE0001421 -STACY RIVERA Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andlor proied specific,PHSrEHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this forth. Ialso certify that all operations will be performed in accordance with all applicable Ordinance Codes ani Standards and State ani <br /> Federal Lewis <br /> APPLICANTS SIGNATURE: Date / I <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type T Check Number Received by <br /> RENS: Wrr Date 2 / 2'l I l Account out: V-6 Date Z /2-7 <br /> COMMENTS: <br /> G9k*-Re-V Nom^' FAu�I-I � Pa�c �Ar,s VA c �S <br /> �,LAS � c I+�s • �2 (,tLtJ �a(i'-�I y So <br />