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Data non 9/26/2014 1:43:07PR SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Repent#5021 <br /> Run by Pagel <br /> Facility Information as of 9/26/2014 <br /> Record Selection Criteria: Facility ID FA0019292 <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 OW0015834 New Owner ID <br /> Owner Name FERMIN ALUSTIZA <br /> Owner DBA FERMIN ALUSTIZA <br /> Owner Address 8250 SEGARINI CT <br /> STOCKTON, CA 95209 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-472-9385 <br /> Mailing Address 8250 SEGARINI CT <br /> STOCKTON, CA 95209 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0019292 10187171 <br /> Facility Name FERMIN ALUSTIZA <br /> Location 820 CHANNEL ST <br /> STOCKTON, CA 95202 <br /> Phone 209-472-9385 x0 <br /> Mailing Address 8250 SEGARINI CT <br /> STOCKTON, CA 95209 <br /> Care of <br /> Location Code Alt Phone <br /> BOS District 001 -VILLAPUDUA Fax <br /> APN 13928013 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 AR0034306 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name FERMIN ALUSTIZA (CinxeOne) <br /> Account Balance as of 9/26/2014: $2,914.00 <br /> (Circle One) <br /> Transfer to Acti �e <br /> Program/Element and Description Record ID Employee ID and Name Status New OwsroR Delete <br /> 1921 -HMBP-Regular-Primary Location PRO528729 EE0009817-ROBERT LOPEZ Active Y N A CII D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0531839 Inactivt Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,ander Pmjact specific,PHSEHD hourly charges associated with this facility <br /> or activity will be billed to the party Identified as the OWNER on this form, l also cedity that all operations will be performed in accordance with all applicable Ordinance Codes ander Standards and State andor <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date / / <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment T a Check Number Recei"M <br /> REHS: _ �— `` Date / 2-� Account out: Date IVie9t J � <br /> COMMENTS: <br />