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Date run 6110/2016 9:29:38AA SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report 95021 <br /> Run by Pagel <br /> Facility Information as of 6/10/2016 <br /> Record Selection Criteria, Facility ID FA00235CB <br /> Make changestcorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: SSN I Fed Tax ID <br /> Owner ID OW0021774 New Owner ID <br /> Owner Name National Distribution Centers LLC <br /> Owner DBA <br /> Owner Address <br /> Home Phone Not Specified <br /> Work/Business Phone 800-922-5088 <br /> Mailing Address 1515 Burnt Mill Rd <br /> Cherry Hill, NJ 08003 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID I CERS ID FA0023508 10670119 <br /> Facility Name National Distribution Centers LLC <br /> Location 11930 S Harlan Rd <br /> Lathrop, CA 95330 <br /> Phone 209-234-1284 x <br /> Mailing Address 11930 Harlan Road <br /> Lathrop, CA 95330 <br /> Care of National Distribution Centers LLC <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 AR0043350 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner 1 Facility / Account <br /> Account Name Randy Kirk (Circle One) <br /> Account Balance as of 6/10/2016: $0.00 <br /> {Circle One) <br /> Trani ActiveAnactve <br /> PrograrnlElemeni and Description Record PD Fmplcyee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Reqular-Primary Location PRO541057 EE0000010-PETER LOMBARDI Active Y N A I D <br /> 2220-SM HW GEN<5 TONSIYR PR0541056 EE0001459-VICKI MCCARTNEY Active 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,PHSIEND 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: Date 1 <br /> Program Records to be TRANSFERFD- '$25.00_ Amount Paid Date / <br /> Water System to be TRANSFERED: Amount Paid Date l <br /> Payment Type Check Number Received y <br /> EHD Staff: ! Date t l�( 1�L7 Account out: Date l�l <br /> COMMENTS: <br /> {� Invoice#: <br /> - <br /> C��� C Pr(A��l��`� �' (� iu aA-Y -\ RC C.s(x-95 <br />