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FRunby <br /> 2/1/2016 4:22:25PM SANJOA IN COUNTY ENVIRONMENTAL HEAL DEPARTMENT <br /> `� Report#5021 <br /> Pagel <br /> Facility Information as of 2/1/2016 <br /> Record Selection Criteria: Facility ID FA0006346 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner : 1 SSN/Fed Tax ID : <br /> Owner ID OW0005059 New Owner ID <br /> Owner Name FRANCISCO, JACK <br /> Owner DBA TOWN & COUNTRY HAY& FEED <br /> Owner Address 8341 ORANGE CT <br /> ALEXANDRIA, VA 22309 <br /> Home Phone 703-780-5372 <br /> Work/Business Phone 703-780-5372 <br /> Mailing Address 8341 ORANGE CT <br /> ALEXANDRIA, VA 22309 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0006346 10182081 <br /> Facility Name TOWN & COUNTRY HAY& FEED <br /> Location 4245 E MAIN ST <br /> STOCKTON, CA 95205 <br /> Phone 703-780-5372 <br /> Mailing Address 4245 E MAIN ST <br /> STOCKTON, CA 95205 <br /> Care of <br /> Location Code 99- UNINCORPORATED P Alt Phone <br /> BOS District 002 - MILLER, KATHERINE Fax <br /> APN 15728211 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name JACK FRANCISCO <br /> Title <br /> Day Phone 703-780-5372 <br /> Night Phone 703-780-5372 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0007700 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name FRANCISCO, JACK (Circle One) <br /> Account Balance as of 2/1/2016: $0.00 <br /> (circle One) <br /> Transferto ACGvernactve <br /> Program/Element and Descriptor, Record ID Employee ID and Name status New OwneO Delete <br /> 2332-EXEMPT TANK FACILITY PRO504808 EE0000027-CINDY VO Active) Y N Alzz�3D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PRO507621 EE0000451 -STEVE SASSON Inactive Y N A I D <br /> 3123-STORMWATER INSPECTION-RETAIL GAS OUT PRO523003 EE0009488-JEFFREY WONG Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,ander project spacff r,PHSIEHD hourly charges associaledwith thisfacility, <br /> or activity will be billed to"party Identified as the OWNER on this form. 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 / / <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Check Number Received b _ <br /> EHD Staff: Date //I(, Account out: Date <br /> COMMENTS. <br /> Invoice#: <br /> e0vfL"C� <br />