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Date run 8!612014 11:14:41AM SAN JO JIN COUNTY ENVIRONMENTAL HEAL 'DEPARTMENT Report#5021 <br /> Run by <br /> Page <br /> Facility Information as of 8/6/2014 <br /> Record Selection Criteria. Facility ID FA0019723 <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 1 Fed Tax ID <br /> Owner ID OW0016180 New Owner ID <br /> Owner Name LINCOLN UNIF SCH DIST <br /> Owner DBA LINCOLN UNIFIED SCHOOL DIST FM <br /> Owner Address 3122 BROOKSIDE RD <br /> STOCKTON, CA 95219 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-953_$700 <br /> Mailing Address 3122 BROOKSIDE RD <br /> STOCKTON, CA 95219 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID f CERS ID FA0019723 10187367 <br /> Facility Name LINCOLN UNIFIED SCHOOL DIST FMC <br /> Location 3122 BROOKSIDE RD <br /> STOCKTON, CA 95219 <br /> Phone 209-953-8585 x0 <br /> Mailing Address 3122 BROOKSIDE RD <br /> STOCKTON, CA 95219 <br /> Care of <br /> Location Code 01 - STOCKTON Alt Phone <br /> BOS District 003 - BESTOLARIDES Fax <br /> APN 11806017 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 AR0035085 New Account ID: _ <br /> Mail Invoices to Owner Mail Invoices to: Owner 1 Facility ! Account <br /> Account Name LINCOLN UNIF SCH DIST (Circle One) <br /> Account Balance as of 81612014: $0.00 <br /> (Circle One) <br /> Transfer to Activellnactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PR0529886 EE0000006-HAZA SAEED Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0533221 Inactive 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,PFISlEFID hourly charges associated with this fatuity <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 andlor Standards and State ardor <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date 1 <br /> Program Records to be TRANSFERED: `$25.00= Amount Paid Date 1 / <br /> Water System to be TRANSFERED: Amount Paid Date 1 J <br /> Payment Type Check Number Received by <br /> REHS: Date / 1 Account out: Date 1 f <br /> COMMENTS. <br />