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Date run 7/24/2017 4:32:34PR SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 7/24/2017 <br /> Record Selection Criteria: Facility ID FA0011114 <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 SSNIFed Tax ID : <br /> Owner ID OW0009114 Case Number: H09302 New Owner ID <br /> Owner Name ELECTRIC LIGHTWAVE <br /> Owner DBA <br /> Owner Address <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address 1610 ISHI GOTO ST <br /> STOCKTON, WA 95206 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0011114 <br /> Facility Name ELECTRIC LIGHTWAVE <br /> Location 1610 ISHI GOTO ST <br /> STOCKTON, CA 95206 <br /> Phone 360-816-5531 <br /> Mailing Address 4400 NE 77TH AVE <br /> VANCOUVER, WA 98662 <br /> Care of <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 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 AR0018114 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name ELECTRIC LIGHTWAVE (Circle One) <br /> Account Balance as of 7/24/2017: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inaclve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner! Delete <br /> 1921 -HMBP-Regular-Primary Location PR0513402 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PR0511114 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,ander project specific,PHSrEHD 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 ander Standards and State andfor <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 /> EHD Staff: Date / /_ Account out: Date / / <br /> COMMENTS: <br /> IOVOICe#: <br />