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Date run 5/15/2015 4:13:39PN SAN JO. JIN COUNTY ENVIRONMENTAL HEA6.. 4 DEPARTMENT Report#5021 <br />Run by a Pagel <br />Facility Information as of 5/15/2015 <br />Record Selection Criteria: Facility ID FA0022939 <br />OWNER FILE INFORMATION Number of facilities for this owner: 1 <br />Owner ID OW0020941 <br />Owner Name Burlington Stores <br />Owner DBA <br />Owner Address <br />Home Phone Not Specified <br />Work/Business Phone 609-387-7800 <br />Mailing Address 1830 Route 130 North <br />Burlington, NJ 08016 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID <br />FA0022939 10626739 <br />Facility Name <br />Burlington Store #571 <br />Location <br />3702 E Hammer Ln <br />Stockton, CA 95212 <br />Phone <br />209-477-6227 x <br />Mailing Address <br />1830 Route 130 North <br />Burlington, NJ 08016 <br />Care of <br />Burlington Stores <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 />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 />Account ID AR0042064 <br />Mail Invoices to Account Mail Invoices to: <br />Account Name Justin Kang <br />Account Balance as of 5/15/2015: $0.00 <br />New Account ID: : <br />Owner / Facility / Account <br />(Circle One) <br />(Circle One) <br />Transferto Active/Inactve <br />Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br />2220 - SM HW GEN <5 TONS/YR PR0540118 EE0000005 - FATINAH ZAREEF 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 protect 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 andlor <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: i� Date y /, /S / /._= Account out: Date / <br />COMMENTS. <br />Invoice #: <br />c�e� ✓>e� } i��J u.. d I Prc� t�G,,, y�A C,ERs <br />