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Date run 6/15/2018 1:18:30PK SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 Run by Pagel Facility Information as of 6/15/2018 Record Selection Criteria: Facility ID FA0009847 OWNER FILE INFORMATION Number of facilities for this owner: 10 Owner ID OW0007847 Case Number: H05625 Owner Name City of Stockton Owner DBA OwnerAddress 6 E LINDSAY ST N STOCKTON, CA 95202 Home Phone Not Specified Work/Business Phone 209-937-8341 Mailing Address 1465 S Lincoln St N Stockton, CA 95206 Care of CRUZ, ADOLFO FACILITY FILE INFORMATION Facility ID/CERS ID FA0009847 10182953 Facility Name STKN OAK PARK Location 500E ALPINE AVE STOCKTON, CA 95204 Phone 209-937-8257 x Mailing Address 605 N ELDORADO ST STOCKTON, CA 95202-1997 Care of City of Stockton Community Services Recreati Location Code 01-STOCKTON Bos District 002 - MILLER, KATHERINE APN 11527001 EMERGENCY NOTIFICATION CONTACT INFORMATION Contact Name Cindy Silligman 5 Title Program Director/Aquatics Speci Day Phone 209-472-9622 ^� Night Phone v s ACCOUNTS RECEIVABLE FILE INFORMATION o/r� Account ID AR0016847 'r- Mail rMail Invoices to Account Make changes/corrections in RED ink. INFORMATION CHANGE (date) OWNERSHIP CHANGE (date) SSN / Fed Tax ID New Owner ID : Alt Phone Fax EMail : Y New Account ID: : Mail Invoices to: Owner / Facility / Account (Circle One) Account Name Brad Mettler v �17 Account Balance as of 6/15/2018: $0.00 �� VJd/� Program/Element and Description e� —11, V - Record ID Employee ID and Name 1921 - HMBP-Reqular-Primary Location PR0519914 EE0009817 - ROBERT LOPEZ 2224 - HAZ MAT BUSINESS PLAN AUTHORIZATION PR0512135 EE0000000 - HAZ MAT SJC OES 2399 - UNIFIED PROGRAM FAC STATE SURCHARGE FI PR0509847 EE0000000 - HAZ MAT SJC OES ERSC - ELECTRONIC REPORTING STATE SURCHARGI PR0531539 (Circle One) Transfer to Active/Inactve Status New Owner? Delete Active Y N AI D Inactive Y N A D Inactive Y N A I D Inactive Y N A I D BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, andror project specific, PHS/EHD hourly charges associated with this 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 Ordinance Codes and/or Standards and State and/or Federal Laws. APPLICANT'S SIGNATURE: Date Program Records to be TRANSFERED: ` $25.00 = Amount Paid Date Water Systemto b TRANSFERED: Amount Paid Date Payment Type Check Number Received by r/ EHD Staff: z-- Date _/ / Account out: Date-7—/,7— COMMENTS: ate/ZCOMMENTS: ` a n � Q� 1I' 4L j O Invoice #: f �.