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Daren" 712!/20114 3:18:43PR SAN J COUNTY ENVIRONMENTAL HEAL"DEPARTMENT Report#5821 <br />Run W 1273 Pagel <br />Facility Information as of 7!25!2014 <br />Record Selection Criteria, Facility ID FA0022456 <br />OWNER FILE INFORMATION Number of facilities for this owner: 1 <br />Owner ID <br />OW0019882 <br />Owner Name <br />FOODLINER INC <br />Owner DBA <br />N <br />Owner Address <br />2099 SOUTHPARK CT 1 <br />PRO511503 <br />DEBUQUE, IA 52003 <br />Home Phone <br />563-584-2672 <br />Work/Business Phone <br />209-941-8361 <br />Mailing Address <br />2099 SOUTHPARK CT STE 1 <br />EE0001421 - STACY RIVERA <br />DUBUQUE, IA 52003 <br />Care of <br />FOODLINER INC <br />FACILITY FILE INFORMATION <br />2361 - UST FACILITY <br />Facility lD/CERS ID <br />FA0022456 10181211 <br />Facility Name <br />FOODLINER INC <br />Location <br />2431 E MARIPOSA RD <br />2399 - UNIFIED PROGRAM FAC STATE SURCHARGE F <br />STOCKTON, CA 95205 <br />Phone <br />209-941-8361 <br />Mailing Address <br />2099 SOUTHPARK CT STE 1 <br />A <br />DUBUQUE, IA 52003 <br />Care of <br />FOODLINER INC <br />Location Code <br />01 - STOCKTON <br />BOS District <br />001 - VILLAPUDUA <br />APN <br />17130003 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name STEVE TERAVSKIS <br />Title <br />Day Phone 209-334-4363 x115 <br />Night Phone 562-230-1844 <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0041099 <br />Mail Invoices to Facility <br />Account Name FOODLINER INC <br />Account Balance as of 7/25/2014: $715.00 <br />Program/Element and Oesaipfion <br />Make changes/comections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />SSN/Fed TaxlD <br />New Owner ID <br />Alt Phone <br />Fax <br />EMail : <br />Record ID Employee ID and Name <br />Mail Invoices to: <br />New Account ID: : <br />Owner / Facility / Account <br />(Circle One) <br />(Cinde One) <br />Transfer to AcWe/Iname <br />Status New Owner? Delete <br />1921 - HMBP-Regular-Primary Location <br />PRO519468 <br />EE0009817 - ROBERT LOPEZ <br />Active <br />Y <br />N <br />A <br />2224 - HAZ MAT BUSINESS PLAN AUTHORIZATION <br />PRO511503 <br />EE0000000 - HAZ MAT SJC DES <br />Inactive <br />Y <br />N <br />A <br />2227 - GEN 5<25 TONS PERMIT <br />PRO513705 <br />EE0001421 - STACY RIVERA <br />Active <br />Y <br />N <br />A <br />2361 - UST FACILITY <br />PR0231818 <br />EE0001421 - STACY RIVERA <br />Inactive <br />Y <br />N <br />A <br />2399 - UNIFIED PROGRAM FAC STATE SURCHARGE F <br />PRO507346 <br />EE0000008 - LETITIA BRIGGS <br />Inactive <br />Y <br />N <br />A <br />2831 - AST FAC >/= 1,320 - <10 K GAL CUMULATIVE <br />PRO528562 <br />EE0001421 - STACY RIVERA <br />Active,! <br />Y <br />N <br />A <br />4740 - WASTE TIRE SITE - EXEMPT <br />PR0523530 <br />EE0009000 - HARPRIT MATTU <br />Active <br />Y <br />N <br />A <br />ERSC - ELECTRONIC REPORTING STATE SURCHARG <br />PR0532596 <br />Inactive <br />Y <br />N <br />A <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1, the undersigned owner, operator a agent of same, acknowledge that all site, and/or project specific, <br />PHS/EHD hourly charges associated with thin <br />or activity will be tolled to the party identified as the OWNER on this form. I also certify that all operations <br />will be performed in accordance with all applicable <br />Ordinance Codes and'or Standards <br />and State <br />Federal Laws. <br />APPLICANTS SIGNATURE: <br />Program Records to be TRANSFERED: <br />Water System to be TRANSFERED: <br />Payment Type Check Number <br />REHS: <br />COMMENTS: <br />Date <br />• $25.00 = Amount Paid Date I/ <br />Amount Paid Date <br />Date <br />Recel <br />Account out: Date <br />D <br />D <br />D <br />D <br />D <br />D <br />D <br />D <br />facility <br />ander <br />