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Date run 11/16/2016 4:01:04P SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 Run by Pagel Facility Information as of 11/16/2016 Record Selection Criteria: Facility ID FA0018651 j Make changes/corrections in RED ink. f i s a' i 't- �% l� INFORMATION CHANGE (date) 7 �% OWNERSHIP CHANGE (date) OWNER FILE INFORMATION Number of facilities for this owner: Owner ID OW0012592 Owner Name Owner DBA OwnerAddress 412 W LUCE STA STOCKTON, CA 952034919 Home Phone, aQG_ 82_4Q6& Work/Business Phone Not Specified Mailing Address STOQKTaU, C'A "29349^,-9 Care of FACILITY FILE INFORMATION Facility ID / CERS ID FA0018651 Facility Name oMERrc ^— RfC=y^'z� Location 412 W LUCE ST STE A STOCKTON, CA 952034919 Phone Mailing Address STOCKTON. TCN GA A52034919 Care of Location Code BOS District APN 16203001 EMERGENCY NOTIFICATION CONTACT INFORMATION Contact Name Title Day Phone Night Phone ACCOUNTS RECEIVABLE FILE INFORMATION Account ID AR0033016 Mail Invoices to Facility Account Name Account Balance 11/16/2016: $0.00 Active/Inactve %-a�s��'of New Owner? Pgram/EI entand�crption Record lD 2 HMBP-Regular-Primary Location PR0528779 2 18 - CRT HANDLER PR0527538 2220 - SM HW GEN <5 TONS/YR PR0527537 ERSC - ELECTRONIC REPORTING STATE SURCHARGI PRO531324 SSN / Fed Tax ID New Owner ID L C r i • C I', _` -7 "? 2 Y -7- 21 T� st G - - V GC L1c1 if 0.. in, Alt Phone Fax EMail : New Account ID: : Mail Invoices to: Owner / Facility / Account (Circle One) I C�L'q Employee ID and Name EE0009817 - ROBERT LOPEZ EE0001421 -STACY RIVERA EE0001421 - STACY RIVERA BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, and/or project specific, PHSIEHD hourly charges a$sociwed with this facility 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 and/or Standards and State and/or Federal Laws. APPLICANT'S SIGNATURE: Date Program Records to be TRANSFERED: * $25.00 = Amount Paid Date Water System to be TRANSFERED: Amount Paid Date Payment Type Check Number Received b EHD Staff: ?� "t ~— Date �i/�/ Account out: Date /�/� COMMENTS: Ir1V01Ce #: (Circle One) Transfer to Active/Inactve Status New Owner? Delete Inactive Y N I D Inactive Y N I D Inactive Y N A I D Inactive Y N A I D BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, and/or project specific, PHSIEHD hourly charges a$sociwed with this facility 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 and/or Standards and State and/or Federal Laws. APPLICANT'S SIGNATURE: Date Program Records to be TRANSFERED: * $25.00 = Amount Paid Date Water System to be TRANSFERED: Amount Paid Date Payment Type Check Number Received b EHD Staff: ?� "t ~— Date �i/�/ Account out: Date /�/� COMMENTS: Ir1V01Ce #: