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Date nm 2/18/2015 2:27:28Pk SAN JOIN COUNTY ENVIRONMENTAL HEA( Report 05021�DEPARTMENT Pagel <br /> Run by <br /> ' Facility Information as of 2/18/2015 <br /> Record Selection Drivers: Fal ID FA0015870 <br /> Io chs INOFORMAON CHANGE(date) <br /> W ERS <br /> ions in RED Ink. <br /> FILE (OR HIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID <br /> Owner ID OW0012791 New Owner ID <br /> Owner Name STOCKTON RURAL CEMETERY <br /> Owner DBA STOCKTON RURAL CEMETERY <br /> Owner Address 2350 CEMETERY LN <br /> STOCKTON, CA 95201 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-465-5213 <br /> Mailing Address 2350 CEMETERY LN <br /> STOCKTON, CA 95204 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0015870 10185033 <br /> Facility Name STOCKTON RURAL CEMETERY <br /> Location 2350 Cemetery Ln <br /> STOCKTON. CA 95201 <br /> Phone 209-465-5213 x0 <br /> Mailing Address PO BOX 241 <br /> STOCKTON, CA 95201 <br /> care of StocktonRural Cemetery <br /> Location Code Alt Phone <br /> BOS District 002 - MILLER, KATHERINE Fax <br /> APN 12536029 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION / <br /> Account ID AR002762> 6 '�f .✓ New Account ID: <br /> Mail Invoices to j:�'%er Mail Invoices to: Owner / Facility / Account <br /> Account Name 9TOCKTON RURAL CEMETERY (Circle One) <br /> Account Balance as of 2/18/2015: $135.00 <br /> (Circe One) <br /> Transfer to Activelmactve <br /> ProgramlElement and Description Record ID Employee ID and N Status New Owner/ Delete <br /> 1920-HMBP-Common Materials PRO523491 EE00098 -ROBERT LOPEZ Active Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PRO535800 EE0009000-HARPRI ATTU Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO533983 InactivE Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT'. I,the undersigned owner,operator or agent of some acknowledge that all site,andor project specifc,PHSrEHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this form. I also rarity that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and State andor <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Mpr 14C5 ybkate �-1 <br /> / ` / L� <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 Received tiv <br /> REHS: Date_/_/_ Account out: Date <br /> COMMENTS: <br />