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Date ran 1/4/2018 2:55:44PM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by <br /> Facility Information as of 1/4/2018 Pagel <br /> Record Selection Criteria: Facility ID FA0022868 <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 OW0020848 New Owner ID <br /> Owner Name Kevin Kelso <br /> Owner DBA KELSOS PAINTING <br /> OwnerAddress 6373 LANDMARK RD <br /> STOCKTON, CA 95215 <br /> Home Phone 209-931-4135 <br /> Work/Business Phone 209-931-4135 <br /> Mailing Address 6373 Landmark Rd <br /> Stockton, CA 95215 <br /> Care of KELSO, KEVIN <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0022868 10628815 <br /> Facility Name Kelso's Painting Inc. <br /> Location 6373 Landmark Rd <br /> Stockton, CA 95215 <br /> Phone 209-931-4135 x <br /> Mailing Address 6373 Landmark Rd ` <br /> Stockton, CA 95215 <br /> Care of Kelso's Painting Inc <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 087-240-030 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name KELSO, KEVIN <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0041945 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name Kevin Kelso (Circle one) <br /> Account Balance as of 1/4/2018: $0.00 <br /> (Circle One) <br /> Program/Element and Description Activisinactve <br /> tion Record ID Employee ID and Name Status New Owner! Delete <br /> 1921 -HMBP-Reqular-Primary Location PRO540018 EE0008709-JAMIE LIMA Active Y N A 0 D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andlor projed specfic,PHSIEHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this forth. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes and/or Standards and State andbr <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 TypCheck Number Received by <br /> EHD Staff: 1 4LO,t— Date / / Account out: Date <br /> COMMENTS: <br /> Invoice#: <br /> �vW1z <br />