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Date run 7/2/2013 8:20:15AM <br />SAN JO/ <br />IN COUNTY ENVIRONMENTAL HEAI DEPARTMENT <br /> Report #5021 <br />Run by <br />Facility Information as of 7/2/2013 <br /> Pagel <br />Record Selection Criteria: Facility ID <br />FA0021452 <br />Make changes/corrections in RED ink. <br /> <br />INFORMATION CHANGE (date) <br /> <br />OWNERSHIP CHANGE (date) <br />OWNER FILE INFORMATION <br />Owner ID <br />Owner Name <br />Owner DBA <br />Owner Address <br />Home Phone <br />Work/Business Phone <br />Mailing Address <br />Care of <br />OW0017639 <br />EH NATIONAL BANK <br />4335 BUSINESS PARK DR STE 200 <br />TEMECULA, CA 92590 <br />951-232-3077 <br />Not Specified <br />4335 BUSINESS PARK DR STE 200 <br />TEMECULA, CA 92590 <br />SSN / Fed Tax ID : <br />New Owner ID : <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID <br />Facility Name <br />Location <br />Phone <br />Mailing Address <br />Care of <br />Location Code <br />BOS District <br />APN <br />FA0021452 <br />STOCKTON PHARMACY <br />3310 E & 3330 E MAIN ST <br />STOCKTON, CA 95205 <br />3310 E MAIN ST <br />STOCKTON, CA 95205 <br />01 - STOCKTON <br />001 - VILLAPUDUA <br />157-110-01 <br />Account ID <br />Mail Invoices to <br />Account Name <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />AR0038828 <br />Account <br />GRIBI ASSOCIATES <br />Account Balance as of 7/2/2013: $-375.00 <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 /> <br />Transfer to Active/I nactve <br />Program/Element and Description Record ID Employee ID and Name Status New Owner? <br /> Delete <br />2950 - ENVIRON ASSESS PRO537339 EE0001699 - JOHNNY YOAKUM Active Y NA ID <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 />APPLICANTS SIGNATURE: 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 />Account out: Date RENS: Date <br />COMMENTS: