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Date mn 12/20/2017 9:04:11A SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 12/20/2017 <br /> Record Selection Criteria: Facility ID FA0010295 <br /> Make changestcorrections in RED ink. y /z �Z��r <br /> INFORMATION CHANGE(date) </ <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID <br /> Owner ID OW0008296 Case Number: H07659 New Owner ID <br /> Owner Name MBM A Wholly Owned Subsidiary of McLane C <br /> Owner DBA MBM INC <br /> OwnerAddress 2641 MEADOW BROOK RD <br /> ROCKY MOUNT, NC 27801 <br /> Home Phone Not Specified <br /> Work/Business Phone 252-985-7200 <br /> Mailing Address 2641 Meadowbrook Road <br /> Rocky Mount, NC 27801 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0010295 10415722 <br /> Facility Name MBM A Wholly Owned Subsidiary of McLane C <br /> Location 26030 S Corporate Ct <br /> Tracy, CA 95377 <br /> Phone 209-839-8173 x <br /> Mailing Address 26030 S Corporate Ct <br /> Tracy, CA 95377 /1 LdI %I <br /> IVAN <br /> Care of MBM A Wholly Owned Subsidiary of McLane C <br /> Location Code 99- UNINCORPORATED A Alt Phone <br /> BOS District 005 - ELLIOTT, BOB 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 AR0017295 p NewAccount ID: <br /> Mail Invoices to Account fff 0/ (�O,b' Mail Invoices to: Owner / Facility / Account <br /> Account Name Terri Batchelor ^I�t" 1111// LLVV// (Circle One) <br /> Account Balance as of 12/20/2017: $7 .00 V I <br /> ` (Circle One) <br /> Program/Element and Description ord ID Employee ID antl Name Status Transfer to Active/Inach e <br /> New Owners Delete <br /> 1921 -HMBP-Reqular-Primary Locatio PR0520213 EE0000009-NICHOLAS LOEHRER Active Y N AD <br /> 2220-SM HW GEN<5 TONS/YR PR0540689 EE0000016-BETTY HO Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PR0512583 EE0000000-HAZ MAT SJC DES Inactive Y N A D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE FI PRO510295 EEOOOo000-HAZ MAT SJC DES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGI PR0533582 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: Lthe undersigned owner,operator or agent of same,acknowledge that all site,anNor project specific,PHWHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this form. I also minify that all operations will be performed in accordance with all applicable Ordinance Codes andlor Standards and State and/or <br /> Federal Laws <br /> APPLICANT'S 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 NumberReceived y <br /> EHD Staff: �.�-P td Date 12/ 2.Z/ 20/7Account out: Date ;2-1 <br /> COMMENTS: <br /> �uyin�55 eLos�� s / Co teo N, o�cns InvDice#: <br /> 6urCc�� rt /The6� ads a 1lte/2'mrG6 4; on 51i-e" 3u5iv�ss dill 6� <br /> iYj0lCtrl/ rU !i1 Jf�t2g6 U cS / WZ�fral 1 5ltpe� I'la1 <br />