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Date run 10/29/2013 3:39:07F SAN JO AN COUNTY ENVIRONMENTAL HEA' 'DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 10/29/2013 <br /> Record Selection Criteria: Facility ID FA0003564 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0002671 New Owner ID <br /> Owner Name BREGANTE, DAVID <br /> Owner DBA BLUE STAR <br /> Owner Address 4040 E MAIN ST <br /> STOCKTON, CA 95205 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-462-0124 <br /> Mailing Address 4040 E MAIN ST <br /> STOCKTON, CA 95205 <br /> Care of BREGANTE, DAVID <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0003564 <br /> Facility Name BLUE STAR <br /> Location 4040 E MAIN ST <br /> STOCKTON, CA 95205 <br /> Phone 209-462-0124 <br /> Mailing Address 102 NOTTINGHAM <br /> STOCKTON, CA 95207 <br /> Care of KEVIN BREGANTE <br /> Location Code 99 - UNINCORPORATED P Alt Phone <br /> BOS District 002- RUHSTALLER, LARRY Fax <br /> APN 15727503 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name DAN IYLER <br /> Title <br /> Day Phone 209-462-0124 <br /> Night Phone 209-462-0124 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0003142 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name BLUE STAR (Circle One) <br /> Account Balance as of 10/29/2013: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Prograrn/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2381 -UST FACILITY(BEFORE 1/84)-obsolete PR0231666 EE0000008-LETITIA BRIGGS Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PRO507349 EE0000008-LETITIA BRIGGS Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge 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 form. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes and/or Standards and Slate andtor <br /> Federal Laws. <br /> APPLICANT'S 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 by <br /> REHS: Date / / Account out: Date / ! <br /> COMMENTS: <br />