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Date run 3/20/2012 4:33:32PN SAN QUIN COUNTY ENVIRONMENTAL HF 'TH DEPARTMENT Report #5021 <br />Run by Pagel <br />Facility Information as of 3/20/2012 <br />Record Selection Criteria: Facility ID FA0007491 <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />OWNER FILE INFORMATION SSN / Fed Tax ID <br />Owner ID OW0005013 New Owner ID : <br />Owner Name VAI=L-E (-PAC-irrIT-T4'GL-E-tJM-$f=RV- ✓dI tty s '. t a c )l -e <br />Owner DBA <br />Owner Address J :- <br />STOCKTON, CA 95206 <br />Home Phone 209-948-9412 <br />Work/Business Phone 209-993-8793 <br />Mallin Address aoQ ^ �onr.ly 1e�rc�T �t / , %, rC<✓t L vC C. <br />9 �crw��z-r� �y-i c�+�1 % y l- � � C,.Jc� �' �' <br />STOCKTON, CA 95206 <br />Care of VAL-L-E-Y 6t-ftM-3fftii- <br />FACILITY FILE INFORMATION <br />Facility ID FA0007491 <br />Facility Name COUNTRY MARKET CARDLOCK �I 11 t r c:< ; F•Z I`r rs ccs v C`�c ot. <br />Location 1524 FRESNO AVE <br />STOCKTON, CA 95206 <br />Phone <br />Mailing Address l"' K i�e'� C i ✓c. �r <br />STOCKTON, CA 95206 <br />Care of ELIASON, MIKE <br />Location Code 01-STOCKTON Alt Phone <br />BOS District 001 - VILLAPUDUA Fax <br />APN 16337025 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 AR0011647 New Account ID: <br />Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br />Account Name COUNTRY MARKET CARDLOCK (Circle One) <br />Account Balance as of 3/20/2012: $0.00 <br />(Circle One) <br />Transfer to Active/Inactve <br />Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br />1921 - HMBP-Regular-Primary Location PRO521056 EE0000000 - HAZ MAT SJC OES Inactive Y N A I D <br />2220 - SM HW GEN <5 TONS/YR PR0518517 EE0001421 -STACY RIVERA Active Y N A I D <br />2224 - HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO513176 EE0000000 - HAZ MAT SJC OES Inactive Y N A I D <br />2301 - UST STATE SURCHARGE FEE PR0516168 EE0002670 - MUNIAPPA NAIDU Inactive Y N A I D <br />2361 - UST FACILITY PR0506545 EE0001421 - STACY RIVERA Active Y N A I D <br />2399 - UNIFIED PROGRAM FAC STATE SURCHARPR0507670 EE0002670 - MUNIAPPA NAIDU Inactive Y N A I D <br />ERSC - ELECTRONIC REPORTING STATE SURCHPR0533714 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, PHS/EHD hourly charges associated with this <br />facility or activity will be billed to the party identified as the OWNER on this form. 1 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. q / <br />APPLICANT'S SIGNATURE: ��aed btu AA/GLQ LZ7G_Zc)1% Date 'j, /.by/ <br />Program Records to be TRANSFERED: J $25.00 - Amount Paid Date <br />Water System to be TRANSFERED: Amount Paid D to <br />Payment Type Check Number Rece <br />REHS: C['/f'n Date Account out: Date <br />COMMENTS: ( 1 <br />\\eh-env\envision\reports\5021. rpt <br />