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E <br /> ;Selection <br /> 12/20/2016 4:42-37F SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENTReport#5x21 <br /> Facility Information as of 1212012016 Rage' <br /> Criteria, Facility ID FA0023799 <br /> Make changes/corrections in RED ink. <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 OW0022162 New Owner ID <br /> Owner Name American Biodiesel Inc <br /> Owner DBA <br /> Owner Address <br /> Home Phone Not Specified <br /> Work/Business Phone 760-942-9306 <br /> Mailing Address PO Box 23-4249 <br /> Encinitas, CA 92023 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0023799 10717633 <br /> Facility Name Community Fuels Terminal <br /> Location 910 Gilmore Ave <br /> Stockton, CA 95203 <br /> Phone 209-466-4823 x <br /> Mailing Address PO BOX 23-4249 <br /> Encinitas, CA 92023 <br /> Care of American Biodiesel Inc <br /> Location Code Alt Phone <br /> BOS District 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 AR0044074 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility 1 Account <br /> Account Name Chris Stowe (Circle One) <br /> Account Balance as of 1212012016: $0.00 <br /> (Circle One) <br /> Transfer to Active,1nactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Reqular-Primary Location PRO541515 EE0009817-ROBERT LOPEZ Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PRO541514 EE0001421 -STACY RIVERA Active Y N A I D <br /> BILLING and COMPL)ANCE ACKNOWLEDGEMENT. I,the undersigned owner,operator or agent of same,acknowledge that all site,andlor project specific,PHSlEHD 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 Stale and'or <br /> Federal Laws <br /> APPLICANT'S SIGNATURE: Date 1 1 <br /> Program Records to be TRANSFERED `$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date 1 1 <br /> Payment Type Number Received by <br /> EHD Staff: pa Datelu�?- Account out: Date 1-,2--/-"71 I <br /> COMMENTS. <br /> C C sLAO 2�J2 /J11 Invoice#: <br /> 2 �. <br /> D �� <br />