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Date run 2/27/2015 8:49:27Ah SAN J(WIN COUNTY ENVIRONMENTAL HEAL DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 2/27/2015 <br /> Record Selection Criteria: Facility ID FA0022800 <br /> Make changeslcorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN 1 Fed Tax ID <br /> Owner ID OW0020687 New Owner ID <br /> Owner Name Gary Alegre <br /> Owner DBA <br /> Owner Address <br /> Home Phone Not Specified <br /> Work/Business Phone 209-932-0495 <br /> Mailing Address 743 W. Anderson St. <br /> Stockton, CA 95206 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID 1 CERS ID FA0022800 10619341 <br /> Facility Name Blue Mountain Minerals <br /> Location 1001 Humphrey S Dr <br /> Stockton, CA 95203 <br /> Phone 209-932.0495 x <br /> Mailing Address 743 W. Anderson St. <br /> Stockton, CA 95206 <br /> Care of Michael Vilarino <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 AR0041814 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner 1 Facility 1 Account <br /> Account Name Michael Vilarino (Circle Ona) <br /> Account Balance as of 2127/2015: $0.00 <br /> {Circle One} <br /> Transfer to ActiveAnactve <br /> P <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> X+/1921 -HMBP-Reqular-Primary location PRO539856 EE0009817-ROBERT LOPEZ Active Y N A 1 D <br /> 12220-_SMI HW GEN<5 TONS/YR PR0539855 EE0001421 -STACY RIVERA Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andlor project specific,PHSIEHD hourly charges associated with this facility <br /> or activity will be billed 10 the party identified as the OWNER on this form. I also certify that all operations wily be performed in accordance with all applicable Ordinance Codes ardlor standards and State andlor <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date ! ! <br /> Program Records to be TRANSFERED: `$25.00= Amount Paid Date 1 t <br /> Water System to be TRANSFERED: Amount Paid Date 1 I <br /> Payment Type Check Number Received Jay !z 1 ! <br /> REH& Date 2 1 rL� 1 ! Account out: �5 Date <br /> COMMENTS: <br /> New fo.',t✓I r 17-01-rev-' V aA C_&(L-> . <br />