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Date ren 9/3/2014 4:35:31 PM SAN JO�UIN COUNTY ENVIRONMENTAL HEA*M$DEPARTMENT Report ns021 <br /> Run by Pagel <br /> Facility Information as of 9/3/2014 <br /> Record Selection Criteria: Facility ID FA0014996 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) — eZ01 <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID <br /> Owner ID OW0011993 NewOwner ID <br /> Owner Name GREG MASTERSON rf1bCL� Lope Z <br /> Owner DBA GOLDEN BEAR — ml <br /> Owner Address 2969 LOOMIS RD t 17,05 _. leelee.— I! q{]� <br /> STOCKTON, CA 95205 soril 4on Ili C15a010 <br /> Home Phone Not Specified (o(v e1 40q� <br /> Work/Business Phone 209-547-0902 Oq �V 1 00 Q <br /> Mailing Address 2969 LOOMIS RD <br /> STOCKTON, CA 95205 <br /> Care of <br /> FACILITY FILE INFORMATION T <br /> Facility ID/CERS ID FA0014996 10184841 J S -T CIA t k {�. F Ll i <br /> Facility Name GOLDEN BEAR <br /> Location 2969 LOOMIS RD <br /> STOCKTON, CA 95205 <br /> Phone 209-547-0902 x0 205 3,14 76 S I <br /> Mailing Address 2969 LOOMIS RD <br /> STOCKTON, CA 95205 <br /> Care of <br /> Location Code Aft Phone <br /> BOS District 001 -VILLAPUDUA Fax <br /> APN 17911024 EMai1: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title CIA OL r <br /> Day Phone ttf <br /> Night Phone O <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0025632 New Account ID: <br /> Maillnvoicesto Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name GREG MASTERSON (Circle One) <br /> Account Balance as of 9/3/2014: $0.00 <br /> (Circle One) <br /> Transfer to ActiveMaclve <br /> ProgranvElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1920-HMBP-Common Materials PR0522024 EE0000006-HAZA SAEED Inactive Y NA I D <br /> 2220-SM HW GEN<5 TONS/YR PRO538482 EE0001421 -STACY RIVERA Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0532308 Inactive Y N 1 D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersignetl owner,operator or agent of same,acienowledge that all site,and/or project specific,PHS/EHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this forth I also certify that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and State andor <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: Date I / <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date / ! <br /> Water System to be TRANSFERED: Amount Paid Date I / <br /> Payment Type heck Number Receive <br /> REHS: ate / / Account out: Date /10-/T <br /> COMMENTS: <br /> 3 C_ WA"i"&S <�Di -)- e 4A&I /AOA r�)e(4* �uv # ,'2559x5 <br />