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If V% <br />Date run 2/8/2017 11:06:54AM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 2/8/2017 <br />Record Selection Criteria: Facility ID FA0019687 <br />OWNER FILE INFORMATION Number of facilities for this owner <br />Owner ID <br />OW0016144 <br />Owner Name <br />BOBOLI INTERNATIONAL <br />Owner DBA <br />BOBOLI INTERNATIONAL <br />Owner Address <br />3439 BROOKSIDE RD #104 <br />Mailing Address <br />STOCKTON, CA 95219 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />209-473-3507 <br />Mailing Address <br />3439-B4�KStt3E 3 <br />BOS District <br />Sfi6CKTON,CA--95-21-8— <br />Care of <br />17713036 <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID FA0019687 10187313 <br />Facility Name <br />BOBOLI INTERNATIONAL <br />Location <br />1718 BOEING WAY <br />STOCKTON, CA 95206 <br />Phone <br />209-473-3507 x0 <br />Mailing Address <br />1718 Boeing Way <br />STOCKTON, CA 95206 <br />Care of <br />Boboli International, LLC <br />Location Code <br />01-STOCKTON <br />BOS District <br />001 - VILLAPUDUA, CARLOS <br />APN <br />17713036 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0035049 % <br />Mail Invoices to Account <br />Account Name BOBOLI INTERNATIONAL <br />Account Balance as of 2/8/2017: $404.00 <br />Make changeslcorrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />SSN /Fed Tax ID <br />New Owner ID : <br />G57QD Pgc-,�;c- Ave -0 3,;t <br />S `-dC-lz-'-JV\ G A qVO-73717 <br />Alt Phone <br />Fax <br />EMail : <br />AA a. T <br />S ocALVoA CAS S90-7 - 3'717 <br />Mail Invoices to <br />New Account ID: : <br />Owner / Facility / Account <br />(Circle One) <br />(Circle One) <br />Transfer to Active/Inactve <br />Program/Element and Description Record ID Employee ID and Name Status New OwneO Delete <br />1921 - HMBP-Regular-Primary Location PR0529850 EE0009817 - ROBERT LOPEZ Active Y N A I D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARG PR0532067 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 State andlor <br />Federal Laws. <br />APPLICANT'S SIGNATURE: <br />Program Records to be TRANSFERED: <br />Water System to be TRANSFERED: <br />Payment Type Check Number <br />EHD Staff: <br />COMMENTS <br />* $25.00 = <br />Date <br />Date <br />Amount Paid Date -/-/ <br />_ Amount Paid Date ! / <br />Received by <br />Account out: % Date,-%, /9/17 <br />Invoice #: <br />/�Ii c. ; l �� a dr.(r cs s L►o. n►5 <br />4's <br />