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Date run 5/'3/2014 4:27:27PN SAN JOf JIN COUNTY ENVIRONMENTAL HEAL DEPARTMENT Report#5021 <br />Run by Y — Pagel <br />Facility Information as of 5/13/2014 <br />Record Selection Criteria: Facility ID FA0012655 <br />OWNER FILE INFORMATION Number of facilities for this owner: 1 <br />Owner ID <br />OW0009852 <br />Owner Name <br />BONADONNAS ASPHALT REPAIR <br />Owner DBA <br />Owner Address <br />3883 S EL DORADO ST <br />Transfer to <br />STOCKTON, CA 95206 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />Not Specified <br />Mailing Address <br />PO BOX 6377 <br />PR0530820 EE0009817 - ROBERT LOPEZ <br />STOCKTON, CA 95206 <br />Care of <br />A I D <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID FA0012655 10184313 <br />Facility Name BONADONNAS ASPHALT REPAIR <br />Location 3883 S EL DORADO ST <br />STOCKTON, CA 95206 <br />Phone 209-982-1804 <br />Mailing Address PO BOX 6377 <br />STOCKTON, CA 952060377 <br />Care of <br />Location Code 01 - STOCKTON <br />BOS District 001 - VILLAPUDUA <br />APN 17525056 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name DAVID BONADONNA <br />Title PRESIDENT <br />Day Phone 209-982-1804 <br />Night Phone 209-993-3159 <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 AR0020956 <br />Mail Invoices to Facility Mail Invoices to <br />Account Name BONADONNAS ASPHALT REPAIR <br />Account Balance as of 5/13/2014: $1,916.50 <br />New Account ID: : <br />Owner / Facility / Account <br />(Circle One) <br />APPLICANT'S SIGNATURE. <br />Date <br />(Circle One) <br />Program Records to be TRANSFERED: <br />' $25.00 = <br />Transfer to <br />Active/Inactve <br />Program/Element and Description <br />Record ID Employee ID and Name <br />Status <br />New Owner? <br />Delete <br />1921 - HMBP-Regular-Primary Location <br />PR0530820 EE0009817 - ROBERT LOPEZ <br />Active <br />Y N <br />A I D <br />2399 - UNIFIED PROGRAM FAC STATE SURCHARGE F <br />PR0516519 EE0000451 - STEVE SASSON <br />Inactive <br />Y N <br />A I D <br />2831 - AST FAC >/= 1,320 - <10 K GAL CUMULATIVE <br />PR0516518 EE0001421 - STACY RIVERA <br />Active,l <br />Y N <br />A I D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARG <br />PR0532976 <br />Inactive <br />Y N <br />A I D <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 />APPLICANT'S SIGNATURE. <br />Date <br />Program Records to be TRANSFERED: <br />' $25.00 = <br />Amount Paid <br />Date <br />Water System to be TRANSFERED: <br />Amount Paid <br />Date-/-/ <br />Payment Type Check Number <br />Receive <br />REHS: <br />Date <br />/ _ 1!4 Account out: <br />Date <br />COMMENTS:n <br />/ <br />