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Date run , 3/16/2009 9:49:43AN SAN JO"``UIN COUNTY ENVIRONMENTAL HEAL "kI DEPARTMENT Report#5021 <br /> Run by <br /> Facility Information as of 3/16/20 Pagel <br /> Record Selection Criteria: Facility ID FA0009145 <br /> Make changeslcorrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0007145 Case Number. =H01537 New Owner ID <br /> Owner Name JIM PLUNKETT, TOM KLEIN, CLARK <br /> Owner DBA SAN JOAQUIN BEVERAGE INC <br /> Owner Address <br /> RECEIVED <br /> Home Phone Not Specified <br /> WoNBusiness Phone 209-948-9400 MAN 17 2009 <br /> Mailing Address PO BOX 32164 <br /> STOCKTON, CA 952132164 OFFIGE OF EMERGENGY eEWOES <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0609145 <br /> Facility Name SAN JOAQUIN BEVERAGE INC <br /> Location 1401 S FRESNO AVE <br /> STOCKTON, CA 95206 <br /> Phone 209-948-9400 <br /> Mailing Address PO BOX 32164 <br /> STOCKTON, CA 952132164 <br /> Care of <br /> Location Code 01 -STOCKTON Alt Phone 0' <br /> BOS District 001 -GUTIERREZ, STEVE Fax <br /> APN 163-370-03 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 AR0016145 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility 1 Account <br /> Account Name SAN JOAQUIN BEVERAGE INC. (Circle One) <br /> Account Balance as of 3/16/2009: $657.00 <br /> (Circle One) <br /> Transfer to ActNellnactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2220-SM HW GEN<5 TONS/YR PRO513670 EE0008317-RAYMOND VON FLUE_ Active Y N A l D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO511433 EE0000000-HAZ MAT SJC OES Inactive Y N A i D <br /> 2244-PACT TRANSFER RECORD-OES PR0519418 EE0000000-HAZ MAT SJC CES Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHAIRPR0509145 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2831 -AST FAC >/=1,320-X10 K GAL CUMULATAPR0516357 EE0008317-RAYMOND VON FLUE Active Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT ' PR0526282 EE0004680-NATALIA SUBBOTNIKO'Active 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,PHSIEHD hourty charges associated with this <br /> facility 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 Ordinace Codes and/or Standards and <br /> State and/or Federal Laws. _ <br /> APPLICANTS SIGNATURE: - ��+ - DBI Beverage San)-nquin <br /> ( 1401 South Fre yvenue <br /> Program Records to be TRANSFERED: Stockton, 95213 <br /> $20.00 a Amount Paid Direct Dial 209 320-2427 <br /> Water System to be TRANSFERED: '$372.00= Amount Paid Martin Gonzales Mobile 209 443-4935 <br /> Payment Type Check Number j Lead Mechanic FAX 209 948-0946martin,gonzales®dbibeverage.com <br /> REHS: Date / / Account out. www.dbibeverage.com <br /> COMMENTS: <br /> CHICO • NAPA SACRAMENTO • SAN FRANCISCO <br /> Ileh envlenvisionLreports15021.rpt SAN JOAQUIN • SAN JOSE • TRUCKEE • UKIAH <br />