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Date run 7/19/2017 4:03:58PK SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report 415021 <br /> Run by Pagel <br /> Facility Information as of 7/19/2017 <br /> Record Selection Criteria: Facility ID FA0002074 <br /> Make changestcorrections 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 OW0010858 New Owner ID <br /> Owner Name County of San Joaquin <br /> Owner DBA SJ CO DEPARTMENT OF AGING <br /> OwnerAddress 333 E WASHINGTON <br /> STOCKTON, CA 95202 <br /> Home Phone 209-468-2202 <br /> Work/Business Phone 468-335-7 <br /> Mailing Address 4520 W Eight Mile Rd. <br /> Stockton, CA 95209 <br /> Care of SC CO DEPARTMENT OF AGING <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0002074 10592548 <br /> Facility Name Kennedy Community Center Pool <br /> Location 2800 S D St <br /> Stockton, CA 95206 <br /> Phone 468-335-7 x <br /> Mailing Address 4520 W. Eight Mile Rd. <br /> Stockton, CA 95209 <br /> Care of Facilities Mngmt. <br /> Location Code 99-UNINCORPORATED A Alt Phone <br /> BOS District 001 -VILLAPUDUA, CARLOS Fax <br /> APN 179-120-01 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name SAN JOAQUIN CO PARKS & RE <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0002082 NewAccount ID: <br /> Mail lnvoicesto Account Mail Invoices to: Owner / Facility / Account <br /> Account Name Mitch Yturrl (Circle One) <br /> Account Balance as of 7/19/2017: $0.00 <br /> (Circle One) <br /> Transfer to Active/InacNe <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Reqular-Primary Location PR0517779 EE0009817-ROBERT LOPEZ Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE FI PRO517780 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 3616-PUBLIC POOL/SPA-EXEMPT PR0360375 EE0008999-LEYNA HUYNH Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all slte,anclor project specifq 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 wrtcy that all operations will be performed in accordance with all applicable Ordinance Codes andfor Standards and State andor <br /> Fedeal 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: Date / /_ Account out: Date / / <br /> COMMENTS: Invoice tf: <br />