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Date run 2/26/2018 1:12:42PR SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 Run by Pagel Facility Information as of 2/26/2018 Record Selection Criteria: Facility ID FA0014910 OWNER FILE INFORMATION Number of facilities for this owner Owner ID OW0011918 Owner Name Owner DBA Active/Inactve OwnerAddress 1240 N FILBERT Delete STOCKTON, CA 95205 Home Phone 28"- 5 Work/Business Phone fiotspmffred Mailing Address P19 -BOX -336 Care of S FACILITY FILE INFORMATION Facility ID / CERS ID FA0014910 Facility Name A Location 1240 N FILBERT STOCKTON, CA 95205 Phone 209-933--0455-- Mailing _ _Mailing Address OX v Care of ST Location Code BOS District APN EMERGENCY NOTIFICATION CONTACT INFORMATION Contact Name Title Day Phone Night Phone ACCOUNTS RECEIVABLE FILE INFORMATION Account ID AR0025439 Mail Invoices to Facility Account Name ANDERSON SIGN & CRANE Account Balance as of 2/26/2018: $0.00 `q Z G Program/Element and Description Record ID Make changes/corrections in RED ink. Zf� INFORMATION CHANGE (date) OWNERSHIP CHANGE (date) SSN / Fed Tax ID New +/Owner ID 461 IL J -2-c' �i II Z 4-a ,.Z0 sl 79-07lo,3 W c a/ j /5-� 91 Alt Phone' Fax EMail : New Account ID: : Mail Invoices to: Owner / Facility / Account (Circle One) � C,I,ti EIuS Employee ID and Name 1921 - HMBP-Reqular-Primary Location PR0522040 EE0009817 - ROBERT LOPEZ 2220 - SM HW GEN <5 TONS/YR PR0521931 EE9999996 - THREE VACANT3 ERSC - ELECTRONIC REPORTING STATE SURCHARGI PR0534299 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 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 and/or Standards and State and/or Federal Laws. APPLICANT'S SIGNATURE: Date Program Records to be TRANSFERED: * $25.00 = Amount Paid Date Water System to be TRANSFERED: Amount Paid Date Payment Ty Check Number Received by EHD Staff: Date // Account out: Date !�e COMMENTS: Invoice #: �/�� (Circle One) Transferto Active/Inactve Status New Owner? Delete Inactive Y NI D Inactive Y N I D Inactive Y N I D 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 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 and/or Standards and State and/or Federal Laws. APPLICANT'S SIGNATURE: Date Program Records to be TRANSFERED: * $25.00 = Amount Paid Date Water System to be TRANSFERED: Amount Paid Date Payment Ty Check Number Received by EHD Staff: Date // Account out: Date !�e COMMENTS: Invoice #: �/��