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Date run 11/6/2014 10:31:11AI SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report W21Run by <br /> Facility Information as of 11/6/2014 Pagel <br /> Record Selection Criteria: Facility ID FA0022653 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID : <br /> Owner ID OW0020269 New Owner ID <br /> Owner Name Harbor Freight Tools USA Inc. <br /> Owner DBA <br /> Owner Address <br /> Home Phone Not Specified <br /> Work/Business Phone 714-625-7520 <br /> Mailing Address 26541 Agoura Rd <br /> Calabasas, CA 91302 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0022653 10591498 <br /> Facility Name Harbor Freight Tools USA, Inc. <br /> Location 1120 Waterloo Rd Ste 4 <br /> Stockton, CA 95205 <br /> Phone 209-467-7041 x <br /> Mailing Address 26541 Agoura Rd <br /> Calabasas, CA 91302 <br /> Care of Harbor Freight Tools USA Inc. <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 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 AR0041469 New Account ID: <br /> Mail Invoices to Account / Mail Invoices to: Owner / Facility / Account <br /> Account Name Mia Espinoza (Circle One) <br /> Account Balance as of 11/6/2014: $0.00 <br /> (Circle One) <br /> Transfer to ActiveMactve <br /> Progrann Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PRO539587 EE0000006-HAZA SAEED Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PR0539586 EE0009488-JEFFREY WONG Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,anNor project specific,PHSrEHD hourly charges associated with this facilily <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 anc/or Standards and State ander <br /> Federal Laws. <br /> APPLICANTS 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 Receive <br /> REHS: 1_,nil Date�/ / l`� _ Account out: Date <br /> COMMENTS: <br /> NW 'FP+Ltt'1 1 PYLOc„RAYl VNA Ct�S <br /> C,4'16 't S <br /> lbw <br />