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Dale mn 2418/2014 9:59:10Ah SAN JOA si COUNTY,ENVIRONMENTAL HEAL',esserDEPARTMENT Report#5021 <br /> Runby 1273Pagel <br /> Facility Information as of 2/18/2014 <br /> Record Selection Criteria'. Facility ID FA0021146 <br /> Make changeshcorrectlons in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <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 9624e- If3 <br /> Home Phone Not Specified <br /> Work/Business Phone 800-800-1353 <br /> Mailing Address 1631 INDUSTRIAL DRG } <br /> STOCKTON, CA 4524C`?60 ` L U5 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0021146 10,187,773 <br /> Facility Name KINGSDOWN INC <br /> Location 1631 INDUSTRIAL DR <br /> STOCKTON, CA 95206 <br /> Phone 209-234-1436 x0 <br /> Mailing Address 1631 INDUSTRIAL DR <br /> STOCKTON, CA 9624e- grj�/p- Tlg� <br /> Care of <br /> Location Code 01 - STOCKTON Alt Phone <br /> BOS District 001 -VILLAPUDUA Fax <br /> APN 17732007 Entail <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 to: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name KINGSDOWN INC (Circle One) <br /> Account Balance as of 2/18/2014: $290.00 <br /> (Circle One) <br /> Transfer to Active/Inachve <br /> Progrem/Elemenl and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PRO536814 EE0009817-ROBERT LOPEZ Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0536826 Inactive Y N A 1 D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andtor project specific,PHS/EHD 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 Codes anNor Standards and State and'or <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 /> Payment Type Check Number Rece d <br /> REHS: Date / / Account out: Da <br /> COMMENT <br />