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Date run 7/1/2010 2:28:21 PM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 7/1/2010 <br /> Record Selection Criteria: Facility ID FA0014439 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> <br /> <br /> <br /> Owner Name BRYAN FREEMAN <br /> Owner DBA MOLLI COOLZ ' <br /> Owner Address 1668 EL PINAL DR 1p <br /> STOCKTON, CA 95205 i0tj, CA 9-55)l <br /> Home Phone Not Specified <br /> Work/Business Phone 209-463-7900 <br /> Mailing Address 1668 EL PINAL DR <br /> STOCKTON, CA 95205 <br /> Care of , <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0014439 <br /> Facility Name MOLLI COOLZ Nuo CIC l S. x <br /> Location 1668 EL PINAL DR <br /> STOCKTON, CA 95205 <br /> Phone 209-463-7900 x0 - <br /> Mailing Address 1668 EL PINAL DR vu p <br /> STOCKTON, CA 95205 <br /> Care of <br /> Location Code Alt Phone _51,01-12) <br /> BOS District Fax - <br /> APN EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name S <br /> Title <br /> t <br /> Day Phone _ <br /> Night Phone ILIVA <br /> PAYM <br /> ACCOUNTS RECEIVABLE FILE INFORMATION RECEIVED <br /> Account ID AR0024519 AUG <br /> New Accoun_D: <br /> Mail Invoices to Owner AUG 1 201OMail Invoices to: wner / Facility / Account <br /> Account Name SAN JOAQUIN COUNTY (Circle One) <br /> Account Balance as of 7/1/2010: $0.00 ENVIRONMENTAL <br /> HEALTH DEPARTMENT (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2244-PACT TRANSFER RECORD-OES PR0519297 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING SURCHARGE PR0533138 Inactive 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 project specific,PHS/EHD hourly charges associated with this <br /> 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 Ordinace Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: TUtDate <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid J,/_S Date _/�/�� <br /> Water System to be TRANSFERED: '$372.00= Amount Paid Date / <br /> Payment Type V/ Check Number Received by <br /> REHS: Z Date / /10 Account out: Tsl�_ Date <br /> COMMENTS: <br /> 7111�° �'o f a l,�rl/ice , <br /> \\eh-env\envision\re orts\5021.r t <br /> P P <br />