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Date run 615/2017 10:31:39AM SAN JOAQUIN COUNTY ENVIRONMENTAL.HEALTH DEPARTMENT <br /> Run by Report#5021 <br /> Facility Information as of 6/5/2017 Pagel <br /> Record Selection Criteria Facility ID FA0022800 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner : 1 OWNERSHIP CHANGE(date) <br /> SSN 1 Fed Tax ID <br /> Owner ID OW0020687 New Owner ID <br /> Owner Name Gary Alegre <br /> Owner DSA <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 FAD022800 10619341 <br /> Facility Name Blue Mountain Minerals <br /> Location 1001 HUMPHREYS 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 EMaid: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name Michael Viiarino <br /> Title General Manager <br /> Day Phone 209-932-0495 <br /> Night Phone 209-649-8651 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account iD AR0041814 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name Michael Vilarino (Circle One) <br /> Account Balance as of 61512017: $0.00 <br /> (Circle One) <br /> Transfer to Activellnactve <br /> Program/Element and Descriptior Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Reqular-Primary Location PRO539856 EE0009817-ROBERT LOPEZ Active Y N AD <br /> 2220-SM HW GEN <5 TONSIYR PR0539855 EE0001421 -STACY RIVERA Active Y N A D <br /> 2832-AST FAC 10 K- /=100 K GAL CUMULATIVE PR0539858 EE0001421 -STACY RIVERA Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENTI.the undersigned owner,operator or agent of same,acknowledge that all site,andfor project specific,PHSIEHD 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 anci Standards and State andlor <br /> Federal Laws <br /> APPLICANT'S SIGNATURE. Date 1 i <br /> Program Records to be TRANSFERED; "$25.00= Amount Paid Date 1 I <br /> Water System to be TRANSFERED: Amount Paid Date / f <br /> Payment Type Check Number Received by <br /> EHD Staff:. �ICiY Account out: <br /> / Date 1 ,4-1 <br /> COMMENTS /2'Vc.r ) 1 <br /> Invaioe#: <br /> ,� <br /> Q � Z�a� <br /> a G b 1 y C1 Al /y, o(AS"Y1le SS 1 S 11V no e,'- �e- ✓q'l 'Ir Z:K3-2 <br /> G�S SIT <br /> Tae)0l c� J r CJ`C. <br />