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Date run 4/27/2016 8:59:05AR SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 Run by Pagel Facility Information as of 4/27/2016 Record Selection Criteria Facility ID FA0012655 OWNER FILE INFORMATION Number of facilities for this owner Owner ID OW0009852 Owner Name BONADONNAS ASPHALT REPAIR Owner DBA Transfer to Owner Address 3883 S EL DORADO ST Status STOCKTON, CA 95206 Home Phone Not Specified Work/Business Phone 209-982-1804 Mailing Address PO BOX 6377 Active STOCKTON, CA 95206 Care of FACILITY FILE INFORMATION Facility ID / CERS ID FA0012655 10184313 Facility Name BONADONNAS ASPHALT REPAIR Location 3883 S EL DORADO ST STOCKTON, CA 95206 Phone 209-982-1804 x Mailing Address PO BOX 6377 STOCKTON, CA 95206-0377 Care of Bonadonna's Asphalt Repair Inc Location Code 01-STOCKTON BOS District 001 - VILLAPUDUA, CARLOS APN 17525056 EMERGENCY NOTIFICATION CONTACT INFORMATION Contact Name DAVID BONADONNA Title PRESIDENT Day Phone 209-982-1804 Night Phone 209-993-3159 ACCOUNTS RECEIVABLE FILE INFORMATION Account ID AR0020956 Mail Invoices to Account Account Name BONADO ASPHALT REPAIR Account Balance as of 4/27/201 $620.5 1D VL -�U Program/Element and DescriptionA , ' Record ID Employee ID and Name 1921 - HMBP-Reqular-Primary Location 'v J PR0530820 EE0009817 - ROBERT LOPEZ 2220 - SM HW GEN <5 TONS/YR PR0538939 EE0001421 - STACY RIVERA 2399 - UNIFIED PROGRAM FAC STATE SURCHARGE F PR0516519 EE0000451 - STEVE SASSON 2831 - AST FAC >/= 1,320 - <10 K GAL CUMULATIVE PR0516518 EE0001421 - STACY RIVERA ERSC - ELECTRONIC REPORTING STATE SURCHARG PR0532976 Make changes/corrections in RED ink. INFORMATION CHANGE (date) OWNERSHIP CHANGE (date) SSN /Fed Tax ID New Owner ID : Alt Phone Fax EMail : New Account ID: Mail Invoices to: Owner / Facility / Account (Circle One) ; 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 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 andlor Standards and State ancYor Federal Laws. APPLICANT'S SIGNATURE: Date Program Records to be TRANSFERED: * $25.00 = Amount Paid Date / / Water System to be TRANSFEREQ Amount Paid Date Payment Tye �Checlber Received b EHD Staff: Date l aG% l Account out: Date Jr l 1 —7 / COMMENTS: Invoice #: (Circle One) Transfer to Active/Inactve Status New Owner? Delete Active Y N AD Active Y N A I D Inactive Y N A D Active Y N A I� D InactivE Y N A I D 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 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 andlor Standards and State ancYor Federal Laws. APPLICANT'S SIGNATURE: Date Program Records to be TRANSFERED: * $25.00 = Amount Paid Date / / Water System to be TRANSFEREQ Amount Paid Date Payment Tye �Checlber Received b EHD Staff: Date l aG% l Account out: Date Jr l 1 —7 / COMMENTS: Invoice #: