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Date mn 12/24/2014 2:12:37F SAN JO�JIN COUNTY ENVIRONMENTAL HEA1� DEPARTMENT Report M5o21 <br /> Run by Pagel <br /> _ Facility Information as of 12/24/2014 <br /> Record Selection Catena: Facility ID FA0021146 <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/FedTaxlD : <br /> Owner ID OW0017421 New Owner ID <br /> Owner Name KINGSDOWN INC <br /> Owner DBA KINGSDOWN INC <br /> Owner Address 1631 INDUSTRIAL DR <br /> STOCKTON, CA 95206-4983 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-234-1436 <br /> Mailing Address 1631 INDUSTRIAL DR <br /> STOCKTON, CA 95206 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0021146 10187773 <br /> Facility Name KINGSDOWN INC <br /> Location 1631 INDUSTRIAL DR <br /> STOCKTON, CA 95206 <br /> Phone 209-234-1436 x <br /> Mailing Address 1631 INDUSTRIAL DR <br /> STOCKTON, CA 95206 <br /> Care of Ray Gutierrez <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 001 -VILLAPUDUA Fax <br /> APN 17732007 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 AR0038131 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility I Account <br /> Account Name KINGSDOWN INC (Circle One) <br /> Account Balance as of 12/24/2014: $0.00 <br /> (Circle One) <br /> Trsnsferto AcWe/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PR0536814 EE0009817-ROBERT LOPEZ Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO536826 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1,Me undersigned owner,operator or agent of same,acknowledge that all site,andor project specific,PHSrEHD hourly charges associated with this facility <br /> or activity will be billed to the party identifed as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and State ands <br /> Federal Laws. <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: [�1Mah �Ll➢ Date /�7y_/ /��-_ Accountout: Date_/ / <br /> COMMENTS: <br />