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Date run 3/14/2016 9:21:51 AN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 3/14/2016 <br />Record Selection Criteria: Facility ID FA0015873 <br />OWNER FILE INFORMATION Number of facilities for this owner <br />Owner ID <br />OW0012794 <br />Owner Name <br />l&BERT - YTrL_ f <br />Owner DBA <br />NUMERI TECH INC <br />Owner Address <br />124 N E ST <br />STOCKTON, CA 95205 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />- <br />Mailing Address <br />PO BOX 5847 <br />STOCKTON, CA 952050847 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID <br />FA0015873 10185039 <br />Facility Name <br />NUMERI TECH INC <br />Location <br />124 N E ST <br />STOCKTON, CA 95205 <br />Phone • <br />2Q9 -8a 9 xO <br />Mailing Address <br />PO BOX 5847 <br />STOCKTON, CA 952050847 <br />Care of <br />Location Code <br />Bos District 001 - VILLAPUDUA, CARLOS <br />APN 15318002 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0027629 <br />Mail Invoices to Owner <br />Account Name -^_G.4T ►iar__ <br />Account Balance as of 3/14/2016: $1,339.00 <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />1 SSN / Fed Tax ID <br />New Owner ID : <br />D,14 4K.,a <br />ll <br />Z0 2-7- Z 7 3 <br />Z-UY ZZ -7 ;73 c! <br />Alt Phone <br />Fax <br />EMail : <br />Dail lii�?C <br />Mail Invoices to <br />New Account ID: : <br />Owner / Facility / Account <br />(Circle One) <br />(Circle One) <br />Transfer to Active/Inactve <br />Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br />1921 - HMBP-Reqular-Primary Location PR0523494 EE0000006 - HAZA SAEED Active Y N A I D <br />2220 - SM HW GEN <5 TONS/YR PR0538497 EE0000027 - CINDY VO Active Y N A I D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARGE PR0531563 Inactive Y N A I D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, and/or project specific, PHS/EHD hourly charges associated with this facility or <br />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 and/or Standards and State anrYor Federal Laws. <br />APPLICANT'S SIGNATURE: It �.�" 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: J 4 Date Account out: Date <br />COMMENTS: <br />Invoice #: <br />