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Date mn 2127/2014 11:49:27AI SAN JO i� IN COUNTY ENVIRONMENTAL HEAL mLEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 2/27/2014 <br /> Record Selection cuum.: Facility ID FA0014996 <br /> Make changeslcorrections in RED ink. / <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0011993 New Owner ID <br /> Owner Name GREG MASTERSON <br /> Owner DBA GOLDEN BEAR Pui.1/LY-�f <br /> Owner Address 2969 LOOMIS RD <br /> STOCKTON, CA 95205 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-547-0902 <br /> Mailing Address 2969 LOOMIS RD <br /> STOCKTON, CA 95205 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0014996 10,184,841 <br /> Facility Name GOLDEN BEAR CU7,_11[, /l P <br /> Location 2969 LOOMIS RD <br /> STOCKTON, CA 95205 <br /> Phone 209-547-0902 x0 <br /> Mailing Address 2969 LOOMIS RD <br /> STOCKTON, CA 95205 <br /> Care of <br /> Location Code Alt Phone <br /> BOIS District 001 -VILLAPUDUA Fax <br /> APN 17911024 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION r <br /> r <br /> Account ID AR0025632 P)OIJ NewAccount ID: <br /> Mail Invoices to Ownt: $7333.0 <br /> " Mail Invoices to: Owner / Facility / Account <br /> Account Name GRESON (Circle One) <br /> Account Balance as of 2/27/2011( I'e — `�s CV t S (Circle One) <br /> Transfer to AcgveMacNe <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1920-HMBP-Common Materials PRO522024E 6044-L LLEN Active Y N A D <br /> 2220-SM HW GEN<5 TONSNR PRO538482 EE0001421 -STACY RIVERA� Active Y N A D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO532308 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT. I,the undersigned owner,operator or agent of same,acl roowedge that all site,andlor project specific,PHSIEHD hourlycharges associatedwith thisfacility <br /> or activity will be billed to the party identified as the OWNER on this forml also candy that all operations will be performed in armrdance with all applicable Ordinance Codes angor Standards and State andror <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment(7��°e Check Number Received bv <br /> REHS: Date / Account out: Date ?--- / /_ <br /> COMMENTS: <br /> P tA �Q� 6 G O Y`-� N 4e4l d'00 , <br /> �'�" P � 7/0, <br />