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Date run 1/5/2017 10:15:05AM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 1/5/2017 <br />Record Selection Criteria: Facility ID FA0010925 <br />OWNER FILE INFORMATION Number of facilities for this owner <br />Owner ID OW0008925 Case Number: H08982 <br />Owner Name DfA <br />Owner DBA <br />OwnerAddress 2050 W FREMONT ST <br />STOCKTON, CA 95203 <br />Home Phone Not Specified <br />Work/Business Phone --473.575—_6S g <br />Mailing Address ,�-g��[ Ate-- <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) /-5—/// 7 _ <br />OWNERSHIP CHANGE (date) <br />SSN / Fed Tax ID <br />New Owner ID : <br />f' . S C <br />i 4? <br />r- <br />kdo-32c-iO3�, <br />✓i /4'" <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID FA0010925 10183939 <br />Facility Name <br />FICE S_ -V--N s <br />s w �C e„�✓� c S <br />Location 2050 W FREMONT ST <br />STOCKTON, CA 95203 <br />Phone —2Qa d��^„?_'2—X_ <br />2 t - I <br />L 3 L> <br />Mailing Address PEI�� <br />(_. l— <br />�-o✓� �- <br />Z. O <br />Care of FQRPEGT nr)oTER <br />I OG -. <br />t Ca <br />Location Code 01-STOCKTON <br />Alt P one <br />BOS District 001 - VILLAPUDUA, CARLOS <br />Fax <br />APN 13336046 <br />EMail: <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name er <br />c U <br />Title <br />Day Phone 20Q -466-5D2 <br />09 <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0017925 <br />New Account ID: <br />Mail Invoices to Account <br />Mail Invoices to: <br />Owner / Facility / Account <br />Account Name OUTFRONT MEDIA <br />Account Balance as of 1/5/2017: $0.00 <br />r �y <br />�-� "F cS <br />(Circle One) <br />C 14 J - <br />(Circle One) <br />Transfer to Active/Inactve <br />Program/Element and Description Record ID <br />Employee ID and Name <br />Status New Owner? Delete <br />1921 - HMBP-Regular-Primary Location PRO520553 <br />EE0009817 - ROBERT LOPEZ <br />Inactive Y N LA A D <br />2220 - SM HW GEN <5 TONS/YR PR0514454 <br />EE0001421 - STACY RIVERA <br />Inactive Y N A I D <br />2224 - HAZ MAT BUSINESS PLAN AUTHORIZATION PR0513213 <br />EE0000000 - HAZ MAT SJC OES <br />Inactive Y N A I D <br />2399 - UNIFIED PROGRAM FAC STATE SURCHARGE FI PR0510925 <br />EE0000000 - HAZ MAT SJC OES <br />Inactive Y N A I D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARGI PR0533531 <br />Inactive Y N A I D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent <br />of same, acknowledge that all site, and/or project specific, PHS/EHD <br />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 <br />Codes and/or Standards and State and/or <br />Federal Laws. <br />APPLICANT'S SIGNATURE: <br />Date <br />Program Records to be TRANSFERED: " $25.00 = <br />Amount Paid Date <br />Water System to be TRANSFERED: <br />Amount Paid Date <br />Payment Ty p Check Number <br />Received by <br />EHD Staff: „ �z_ _ Date /J_ _7 Account out: c Date <br />-7 <br />COMMENTS: <br />Invoice #: <br />