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Date run' 2/5/2015 3:52:29PM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> Run by Report 95021 <br /> Facility Information as of 2/5/2015 Pagel <br /> Record Selection Criteria: Facility ID FA0018143 <br /> Make changles/correctlons In RED Ink. <br /> INFORMATION CHANGE(date) 2 <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID <br /> Owner ID OW0014886 New Owner ID <br /> Owner Name HD Supply Distribution Services, LLC. <br /> Owner DBA HD SUPPLY DISTRIBUTION SERVICE <br /> Owner Address 501 W CHURCH ST <br /> ORLANDO, FL 22385 <br /> Home Phone Not Specified <br /> Work/Business Phone 770-822-9000 <br /> Mailing Address 3100 Cumberland Blvd., MS-1226 <br /> Atlanta, GA 30339 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0018143 10186781 <br /> Facility Name HD Supply Distribution Services, LLC <br /> Location 2055 INDUSTRAIL DR <br /> Stockton, CA 95206 <br /> Phone 404-653-5433 x / x <br /> Mailing Address 2055 Industrial Drive <br /> Stockton, CA 95206 <br /> Care of Dave O'Donnell <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 001 -VILLAPUDUA Fax <br /> APN 17733020 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0031913 ^ ] f New Account ID: <br /> Mail Invoices to Account l`� 1(,�II' �Y—'' Mail Invoices to: Owner / Facility / Account <br /> Account Name Dave o f7V�� ,r., )� (Clmle one) <br /> Account Balance as of 2/512015:($6,!8.00 z/ / <br /> (Circle One) <br /> Transfer r Activee <br /> Program/Element and Description Record 10 Employee 10 and Name Status New Ownefl Delete <br /> 1921 -HMBP-Regular-Primary Location PRO526786 EE0009817-ROBERT LOPEZ Active Y N A YD <br /> 2220-SM HW GEN<5 TONSNR PRO538428 EE0001421 -STACY RIVERA Active Y N A D <br /> 4740-WASTE TIRE SITE-EXEMPT PRO535050 EE0002620-ALFONSO ARAMBULA Inactivf Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO533466 Inactivr Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT I,the undersigned owner,operator or agent of same,acknowledge that all site,incisor project specific,PHS/EHD hourly charges associated with this facility <br /> or aett,h y will be billed to the party identified as the OWNER on this fano. I also carlify that all operations will be pencianetl in accordance with all applicable Ordinance Codes anaor Standards and State ane« <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: \AQ4 ^ - Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid_ Date <br /> Water System to be TRANSFERED: Amount Paid Date / I <br /> Payment Type Check Number Received by <br /> RENS: Date / /_ Account out: t46 Date :;?-- <br /> COMMENTS: \E,aSaL Z, '.�o,i� N`tj_ �o.c.\�ivj ',s `l\o <br /> aK\Z§, o.��,�r," .� b �� S..,ee\� `;zS'.SA"z i ti,.,J:ov\ Syr v-ca,s <br />