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Date ran 5/24/2018 4:56:47PN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Facility Information as of 5/24/2018 Pagel <br /> Record Selection Criteria: Facility 10 FA0003806 <br /> Make changeskorrections in RED ink. P G <br /> INFORMATION CHANGE(date) J z �a <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID <br /> Owner ID OW0002822 New' O1w erID <br /> Owner Name l�/ 1�f <br /> Owner DBA d}}SlMpS f4-eHq� <br /> OwnerAddress 4025 CORONADO AVE <br /> STOCKTON, CA 952042344 <br /> Home Phone Not Specified <br /> Work/Business Phone 299-466-1477-- <br /> !A Mailing Address -po-BgX-8640- <br /> ST0GKT-GN-GA-9520& -. <br /> Care of <br /> FACILITY FILE INFORMATION Site Mitigation Facility <br /> Facility ID/CERS ID FA0003806 10181437 <br /> Facility Name _ — <br /> Location 4025 CORONADO AVE <br /> STOCKTON, CA 95204 <br /> Phone John Neil Stevens <br /> Vice President <br /> Mailing Address Real Estate Asset Manger <br /> S+AEK4-_G -6A-952(A <br /> Care of Credit Management Group <br /> Location Code 01 -STOCKTON MAC A0397-031 <br /> 1655 BOS District 002-MILLER, KATHERINE Concorants945t. Floor <br /> Concord,CA 94520 <br /> APN 11530025 Tel, 9254839403 <br /> Fax: 925 483 9116 <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION Cell:510 206 7818 <br /> Contact Name /'' wells Fargo Bank,N.A. john.ste ns@wellsfargo.com <br /> Title 1 /V <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION p <br /> Account ID AR0003391 �/ G, NeW Account ID: <br /> Mail Invoices to Account III yolclys to: Owner / Facility / Account <br /> Account Name KFystal jaek9 I/` ^ 0N�VVV (Glide one) <br /> Account Balance as of 5/24/2018: $1 .10 V ^ <br /> I (Circle One) <br /> Tansfer to Adive�[nec[ve <br /> Program/Element and Description Record ID EmploAeIDName Status New OwneR Delete <br /> 1921 -HMBP-Regular-Primary Location PRO526240 EE0009817-ROBERT LOPEZ Active Y N AD <br /> 2221 -USED OIL ONLY-<5 TONSNR PRO538460 EE0001421 -STACY RIVERA Active Y N A D <br /> 2381 -UST FACILITY(BEFORE 1/84)-obsolete PR0231068 EE0000008-LETITIA BRIGGS Inactive Y N A D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGI PR0534381 InactiVE Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,ardor project specific,PHS/EHD hourly charges associated with this facility <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 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"e TRANSFERED: Amount Paid Date / / <br /> Payment Typ Check Number Received by <br /> EHD Staff: Date�_/ " 1 l Account out: Date <br /> COMMENTS: <br /> Invoice#: <br />