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Date run 10/612015 11:44:22AI SAN JOAVN COUNTY ENVIRONMENTAL HEALReport#5021 <br /> Run <br /> Pagel <br /> Run by <br /> Facility Information as of 10/6/2015 <br /> Record Selection Criteria: Facility ID FA0011139 <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 OW0009139 Case Number: H09333 New Owner ID <br /> Owner Name WAGNER MECHANICAL <br /> Owner DBA WAGNER MECHANICAL <br /> Owner Address 11149 N SHELTON RD <br /> LINDEN, CA 95236 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-463-0193 <br /> Mailing Address 11149 N SHELTON RD <br /> LINDEN, CA 95236 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0011139 10184093 <br /> Facility Name WAGNER MECHANICAL <br /> Location 937 W CHURCH ST <br /> STOCKTON, CA 95203 <br /> Phone 209463-0193 x <br /> Mailing Address 11149 N SHELTON RD <br /> LINDEN, CA 95236 <br /> Care of Jeff Wagner <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 001 -VILLAPUDUA, CARLOS Fax <br /> APN 14524047 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 AR0018139 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name WAGNER MECHANICAL (Circle one) <br /> Account Balance as of 10/6/2015: $0.00 <br /> (Circle One) <br /> Transfer to Activellnaclve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Reqular-Primary Location PRO520696 EE0009817-ROBERT LOPEZ Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PR0513427 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PR0511139 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO532657 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andor project specific,PHWHD hourly charges associated with this facility <br /> or activity,will be billed to the party identified as the OWNER on this fano. I also certify 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: 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: Date /_I_ Account out: Date <br /> COMMENTS: Invoice#: <br />