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Date m' 7/22014 10:15:40AM SAN JOA UiN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />Report #5021 <br />Pagel <br />Run by 1273 Facility Information as of 7/2/2014 <br />Record Selection Criteria: Facility ID FA0003541 <br />OWNER FILE INFORMATION Number offacilities for this owner: <br />Owner ID GAjJ0e0264- ev <br />Owner Name FOodliner, Inc. <br />Owner DBA <br />Owner Address 2431 E MARIPOSA RD <br />STOCKTON, CA 95205 <br />Home Phone Not Specified <br />Work/Business Phone 563-584-2672 <br />Mailing Address 2099 Southpark Court, Suite 1 <br />Dubuque, IA 52003 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility lD/CERS ID <br />6A090854'1 't99'e'12"_ <br />Facility Name <br />Foodliner, Inc. <br />Location <br />2431 E Mariposa Rd <br />A I D <br />STOCKTON, CA 95205 <br />Phone <br />209-941-8361 x <br />Mailing Address <br />2099 Southpark Court, Suite 1 <br />N <br />Dubuque, IA 52003 <br />Care of <br />Steve Hronek <br />Location Code <br />01-STOCKTON <br />BOS District <br />001 - VILLAPUDUA <br />APN <br />17130003 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID-AR0003120- <br />Mail Invoices to Facility <br />Account Name FOodliner, Inc. <br />Account Balance as of 7/2/2014: $0.00 <br />Program/Element and Description <br />Make changes/corrections In Ittu mlr. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />SSN/Fed Tax ID <br />New Owner ID : <br />Site Mitigation Facility <br />Alt Phone <br />Fax <br />EMail : <br />Record ID Employee ID and Name <br />New Account ID: : <br />Mail Invoices to: Owner / Facility / Account <br />(Circle One) <br />(Circle One) <br />Transfer to Active/mame <br />Status New Owner? Delete <br />1921 - HMBP-Regular-Primary Location <br />PR0519468 <br />EE0009817 - ROBERT LOPEZ <br />Active <br />Y <br />N <br />A I D <br />2224 - HAZ MAT BUSINESS PLAN AUTHORIZATION <br />PRO511503 <br />EE0000000 - HAZ MAT SJC OES <br />Inactive <br />Y <br />N <br />A I D <br />2227 - GEN 5<25 TONS PERMIT <br />PRO513705 <br />EE0001421 - STACY RIVERA <br />Active <br />Y <br />N <br />A I D <br />2361 -UST FACILITY <br />PR0231818 <br />EE0001421-STACY RIVERA <br />Inactive <br />Y <br />N <br />A I D <br />2399 - UNIFIED PROGRAM FAC STATE SURCHARGE F <br />PR0507346 <br />EE0000008 - LETITIA BRIGGS <br />Inactive <br />Y <br />N <br />A I D <br />2831 - AST FAC >/= 1,320 - <10 K GAL CUMULATIVE <br />PR0528562 <br />EE0001421 - STACY RIVERA <br />Active,l <br />Y <br />N <br />A I D <br />4740 - WASTE TIRE SITE - EXEMPT <br />PRO523530 <br />EE0009000 - HARPRIT MATTU <br />Active <br />Y <br />N <br />A I D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARG <br />PRO532596 <br />Inactive <br />Y <br />N <br />A I D <br />4630- NTNC WATER SYSTEM <br />WA0461334 <br />EE0005838- ADRIENNE ELLSAESSER <br />Active <br />Y <br />N <br />A I D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent <br />of same, ai*nowledge that all site, andor project speck, PHS/EHD <br />hourly charges <br />associated with this facility <br />or activity will the billed to the parry identified as Ne OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ortlinance <br />Codes andior <br />Standards <br />and Slate andor <br />Federal I. <br />APPLICANT'S SIGNATURE: <br />Date <br />Program Records to be TRANSFERED: ' $25.00 = <br />Amount Paid Date / <br />/ <br />Water System to be TRANSFERED: <br />Amount Paid Date <br />/ / <br />Payment Type Check Number <br />Received by <br />RENS: __- Date <br />/ <br />/ Account out: Date <br />I/ <br />COMMENTS <br />