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Date ern 12/20/2016 8:39:36A SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Repcd#5021 <br /> Run by <br /> Facility Information as of 12/20/2016 Pagel <br /> Record Selection Criteria: Facility ID FA0023415 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) l zo /f- <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID : <br /> Owner ID OW0021648 New Owner ID <br /> Owner Name VILLARREAL, LIONEL <br /> Owner DBA <br /> OwnerAddress 1501 W CHARTER WAY#B <br /> STOCKTON, CA 95206 <br /> Home Phone 415-926-3946 <br /> Work/Business Phone Not Specified <br /> Mailing Address 1501 W CHARTER WAY#B <br /> STOCKTON, CA 95206 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0023415 <br /> Facility Name Al MOBIL COMPANY <br /> Location 1501 W CHARTER WAY#B <br /> STOCKTON, CA 95206 <br /> Phone 415-926-3946 <br /> Mailing Address 1501 W CHARTER WAY#B <br /> STOCKTON, CA 95206 <br /> Care of VILLARREAL, LIONEL <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 001 -VILLAPUDUA, CARLOS Fax <br /> APN 16337016 EMail <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name VILLARREAL, LIONEL <br /> Title <br /> Day Phone 415-926-3946 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0043165 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name Al MOBIL COMPANY , (Circle One) <br /> Account Balance as of 12/20/2016: $341.50 <br /> (Circle One) <br /> Transfer to Aciivednaclve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner! Delete <br /> 1921 -HMBP-Regular-Primary Location PR0540948 EE0009817-ROBERT LOPEZ Active Y N A U D <br /> 2831 -AST FAC >/=1,320-<10 K GAL CUMULATIVE PRO540916 EE9999998-ONE VACANTI Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge Mat all site,andor project specific,PHSfEHO hourly charges associated with this facility, <br /> a 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 andor Standards and State ardl <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: Date <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 by <br /> EHD Staff: ,,,ft-Z Date J 2- / Zt2 / s Account out: Date�/ 7-3 <br /> COMMENTS: <br /> Invoice#: <br />