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Date nm 11/3/2017 10:42:03AP SAN UIN JOA COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> Run by Q person#5021 <br /> Facility Information as of 11/3/2017 Pagel <br /> Record Selection Criteria: Facility ID FA0024018 <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 <br /> SSN/Fed Tax ID <br /> Owner ID OW0022488 New Owner ID <br /> Owner Name Port of Stockton <br /> Owner DBA <br /> OwnerAddress 2201 W WASHINGTON ST <br /> STOCKTON, CA 95203 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-946-0246 <br /> Mailing Address PO BOX 2089 <br /> Stockton, CA 95201 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0024018 10725232 <br /> Facility Name STOCKTON PORT DIST(STOCKTON, CA) <br /> Location 804 Humphreys Dr <br /> Stockton, CA 95203 <br /> Phone 209-946-0246 x <br /> Mailing Address 2201 W Washington St <br /> Stockton, CA 95203 <br /> Care of Stockton Port District 11I� a 171 ( V <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 162-030-01 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0044577 New Account ID: <br /> Mail Invoices to Account O Mail Invoices to: Owner / Facility / Account <br /> Account Name ,Jason Cas an (Circle One) <br /> Account Balance as of 11/3/2017: 36.00 <br /> (Gird¢One) <br /> Program/Element and Description Record lD Employee lD and Name Transferlo Active/Inactve <br /> Status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PR0541877 EE0009817-ROBERT LOPEZ Active Y N A D <br /> 2220-SM HW GEN<5 TONS/YR PRO541876 EE0001421 -STACY RIVERA Active Y N A (D D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project speck,PHS/EHD hourly charges associated with this facility <br /> or activity will be billed to the pally identified as the OWNER on this form. I also codify that all operations will be performed in acconcance with all applicable Ordinance Codes andor Standards and Stale andor <br /> Federal 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 /> Payme Type heck Number Received by <br /> EHDSt Date_/, Accout: _ Date <br /> COMMENTS: unt o <br /> Invoice#: <br />