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Date run 3/26/2018 9:53:41AN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 3/26/2018 <br /> Record Selection Crilena: Facility ID FA0017247 <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/Fed Tax ID <br /> Owner ID OW0014088 New Owner ID <br /> Owner Name POLK, JACQUELINE <br /> Owner DBA JACQUELINE POLK <br /> Owner Address 10549 N JACK TONE RD <br /> STOCKTON, CA 95212 <br /> Home Phone 209-931-1391 <br /> Work/Business Phone Not Specified <br /> Mailing Address 10549 N JACK TONE RD <br /> STOCKTON, CA 95212 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0017247 10186145 <br /> Facility Name JACQUELINE POLK <br /> Location 10549 N JACK TONE RD <br /> STOCKTON, CA 95212 <br /> Phone 209-931-1391 <br /> Mailing Address 10549 N JACK TONE RD <br /> STOCKTON, CA 95212 <br /> Care of 1 <br /> Location Code 99- UNINCORPORATED A Alt Phone <br /> BOS District 004-WINN, CHARLES Fax <br /> APN 06321023 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone ( p <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0030129A New Account ID: <br /> Mail Invoices to Owner y,l✓ I aJ Mail Invoices to: Owner / Facility / Account <br /> Account Name POLK. JACQUELINE \ V (Circle One) <br /> Account Balance as of 3/26/2018: $222.00 <br /> (Circle One) <br /> Transfer to ActiveAnai <br /> PmgramlElement and Description Record ID Empl yet ID and Name Status New Owner? Delete <br /> 1958-HM-Farm Operations PRO525432 EE0002670-MUNIAPPANAIDU Active Y N A I D <br /> 2221 -USED OIL ONLY-<5 TONS/YR PRO630346 EE0001459-VICKI MCCARTNEY Active Y N A D <br /> 2830-AST FAC -SPCC EXEMPT PRO530345 EE0000030-AARON HANG Inactive Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PR0535718 EE0007379-AMANDA BOERTIEN Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGI PR0531561 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andfor 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 candy that all operations will be performed in accordance with all applicable Ordinance Codes ancvor Standards and State and'or <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date / / <br /> Program Records to be TRANSFERED: •$25.00= Amount Paid Date <br /> Water System to be TRANSFEREO: Amount Paid Date / / <br /> Payment Type Check Number Received by f/ <br /> EHD Staff: Date —Account out: L6 Date <br /> COMMENTS: �/ I <br /> Bim`-`^ or 3`,73/15 /nSPeG��oN Invoice#. <br />