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Datemn 8/28/2014 1:50:18PR SAN JC`�JIN COUNTY ENVIRONMENTAL HEA DEPARTMENT Report x5021 <br /> Rw by1.01 Page? <br /> Facility Information as of 8/28/2014 <br /> Record Selection Criteria: Facility ID FA0014546 <br /> Make changesicorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 2 SSN/Fed Tax ID : <br /> Owner ID OW0011570 New Owner ID <br /> Owner Name EXTENDED STAY CA INC <br /> Owner DBA EXTENDED STAY AMERICA <br /> Owner Address 100 DUNBAR ST <br /> SPARTANBURG, SC 29306 <br /> Home Phone 209-472-7588 <br /> Work/Business Phone Not Specified <br /> Mailing Address PO BOX 49550 <br /> CHARLOTTE, NC 28277-9550 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0014546 10184703 <br /> Facility Name EXTENDED STAY AMERICA#8794 <br /> Location 2844 W MARCH LN <br /> STOCKTON, CA 95219 <br /> Phone 209-472-7588 <br /> Mailing Address PO BOX 49550 <br /> CHARLOTTE, NC 28277-9550 <br /> Care of TAX DEPT <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOIS District 003- BESTOLARIDES Fax <br /> APN 11802004 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0024745 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name EXTENDED STAY AMERICA#8794 (circle One) <br /> Account Balance as of 8/28/2014: $0.00 <br /> (Circle One) <br /> Transfer to Active/lnacive <br /> PrograMElemenl and Description Record 10 Employee ID and Name Status New OwneO Delete <br /> 1921 -HMBP-Regular-Primary Location PRO530824 EE0000006-HAZA SAEED Active Y N A , I D <br /> 2409-HOTEL/MOTEL>90 PR0521424 EE0008987-SCOTT SANGALANG Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0531488 Inactiv( Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1,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 ands <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 Rer by <br /> REHS: Date_/ /_ Account out: Date <br /> COMMENTS: <br />