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Date run 9/6/2017 9A2:03AM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 9/6/2017 <br /> Record Selection Cntena: Facility ID FA0018376 <br /> Make changes(corrections in RED ink. <br /> INFORMATION CHANGE(date) �Q / <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 cRN/Fed Tax ID <br /> Owner ID OW0015095 I <br /> Owner Name LAURIEANDERSON <br /> Owner DBA ACE Fremont Plaza Ace Hardware <br /> OwnerAddress 2060 E FREMONT ST 2d60 E. Fremont street, Stockton, CA 95205 <br /> STOCKTON, CA 95205 (209) 451-1459 • Fax: (209) 451-1610 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-464-0725 <br /> Mailing Address 2060E FREMONT ST <br /> STOCKTON, CA 95205 Bill Stoermer <br /> Care of AOwner <br /> HeldWero (209) 612-5573 <br /> FACILITY FILE INFORMATION bstoermeresanda/woodme.com <br /> Facility ID/CERS ID FA0018376 <br /> Facility Name ACE <br /> Location 2060 E FREMONT ST _ <br /> STOCKTON, CA 95205 _ Fremont Plaza Ace Hardware <br /> Phone 209464-0725 x0 ' <br /> Mailing Address 2060 E FREMONT ST 2060 E. Fremont Street, Stockton, 95205 <br /> STOCKTON. CA 95205 (209) 451-1459 Fax: com <br /> Care of 09) 45151 1610 <br /> Email: BHIb1erOFremontPlazaFice.cam <br /> Location Code Alt II, <br /> BOS District Fax Brandon Hibler <br /> APN EM Operations Manager <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION . (209) 986-8207 <br /> Contact Name Nardwere www.FrefsontP1azaAce.com <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0032423 NewAccount ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name LAURIEANDERSON Z (Circle One) <br /> Account Balance as of 9/6/2017: $0.00 1q2- 1 X <br /> (Circle One) <br /> Transfer to Active/InacNe <br /> Program/Element and Description - Record ID Employee ID and Name Status New Owner?�J�^,/Delete <br /> 1921 -HMBP-Reqular-Primary Location PR0527117 EE0009817-ROBERT LOPEZ Inactive Y N O A' 'I D <br /> BILLING and COMPLIANGEACKNOWLEOGEMENT: (,the undersigned owner,operator or agent of same,acknowledge that all site,androrprojecl speck,PHS/EHD hourly charges associat(Af� lyi�th Is 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 anNor Standards and ate and/or <br /> Federal Laws, <br /> APPLICANT'S SIGNATURE: - Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System a TRANSFERED: Amount Paid Date <br /> Payment Ty e T Check Number Received by <br /> EHD Staff: �-Z <br /> Date--j LL Account out: .) Date / —7 j t <br /> COMMENTS: i <br /> Invoice#: <br />