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Date nm 7/2/2014 12:13:06PM SAN JOA�INCOUNTYENVIRONMENTAL HEAL�EPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 7/2/2014 <br /> Record Selection Criteria: Facility ID FA0022366 <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 OW0018766 New Owner ID <br /> Owner Name SAN JOAQUIN COUNTY OFFICE OF EMER( <br /> Owner DBA <br /> Owner Address 2101 E EARHART AVE 300 <br /> STOCKTON, CA 95206 <br /> Home Phone 209-953-6200 <br /> Work(Business Phone Not Specified <br /> Mailing Address 2101 E EARHART AVE STE 300 <br /> STOCKTON, CA 95206 <br /> Care of COCKRELL, MICHAEL <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0022366 10505053 <br /> Facility Name OFFICE OF EMERGENCY SERVICES SAN J <br /> Location 2101 E EARHART AVE STE 300 <br /> STOCKTON, CA 95206 <br /> Phone 209-953-6200 <br /> Mailing Address 2101 E EARHART AVE STE 300 <br /> STOCKTON, CA 95206 <br /> Care of COCKRELL, MICHAEL <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name MICHAEL CROCKRELL <br /> Title <br /> Day Phone 209-953-6200 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0040916 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name OFFICE OF EMERGENCY SERVICES SAN JOAQUI (cimleCoal <br /> Account Balance as of 7/2/2014: $1 0 <br /> D/(� (Circle One) <br /> "T Transfer to ACGvellnactve <br /> PmgaMElem¢M and Description Record ID Employee ID and Name BteW8 New Owner' Delete <br /> 1920-HMBP-Common Materials PR0538938 EE0008709-JAMIE DE LA ROSA vH Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agentof same,acknowledge that all site,andor project specfic, &EHDhoudy charges associated with this facility <br /> or activity will be billed to"party identified as the OWNER on this farm. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and State andar <br /> Federal Leis. <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 /> REHS: Date_/ /_ Account out: _���L Date—/ -7— <br /> COMMENTS:COMMENTS: <br /> m� dA'?4 w • Ali rbc -/P <br />