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Date run 121312015 9:30:44AN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 12/3/2015 <br /> Record Selection Criteria: Facility ID FA0021145 <br /> Make changestcorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID <br /> Owner ID OW0017420 New Owner ID <br /> Owner Name MARK CONRAD <br /> Owner DBA CONQUEST IMAGING <br /> Owner Address 1815 INDUSTRIAL DR <br /> STOCKTON, CA 95206 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-942-2654 <br /> Mailing Address 1815 INDUSTRIAL DR <br /> STOCKTON, CA 95206 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility IDICERS ID FA0021145 10187771 <br /> Facility Name CONQUEST IMAGING <br /> Location 1815 INDUSTRIAL DR <br /> STOCKTON, CA 95206 <br /> Phone 209-942-2654 x0 <br /> Mailing Address 1815 INDUSTRIAL DR <br /> STOCKTON, CA 95206 <br /> Care of <br /> Location Code 01 - STOCKTON Alt Phone <br /> BOS District 001 -VILLAPUDUA, CARLOS Fax <br /> APN 17733028 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 AR0038130 New Account ID: <br /> Mail Invoices to Owner Mail Invoices IQ: Owner 1 Facility 1 Account <br /> Account Name MARKCONRAD 4 (circle one) <br /> Account Balance as of 12!312015: $0.00 lea 16 / 14 Ct — <br /> r (Circle One) <br /> J Transfer to Activefinactve <br /> Progra"Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PRO536813 EE0009817-ROBERT LOPEZ ActiveY N A i D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0536846 InactivE Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific,PHSIEHD 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 andlor Standards and State andlor <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: Date 1 1 <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date 1 1 <br /> Water System to be TRANSFERED: Amount Paid Date 1 1 <br /> Payment Type Check Number Received b <br /> Ell Staff: ;-- Date d z4- —3 !� Account out: _ Date <br /> C�OMMME`NlT�S: �/�/� 1,' / may Invoice <br /> I/ <br /> 1 4(- e__ <br /> cc f cc CIL <br /> s ``tel <br />