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I <br /> Date run 2/25/2015 10:41:51 AI SAN JReport#5021 <br /> ON COUNTY ENVIRONMENTAL HEAL�EPARTMENT Pagel <br /> Run by <br /> Facility Information as of 2/25/2015 <br /> Record Selection Criteria: Facility ID FA0009794 <br /> Make changesicorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 86 SSN/Fed Tax ID : <br /> Owner ID OW0001176 New Owner ID <br /> Owner Name CITY OF STOCKTON <br /> Owner DBA <br /> Owner Address 425 N EL DORADO ST <br /> STOCKTON, CA 95202 <br /> Home Phone 209-937-8212 <br /> Work/Business Phone 209-937-8341 <br /> Mailing Address 425 N EL DORADO ST <br /> STOCKTON, CA 95202 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0009794 10182913 <br /> Facility Name CITY OF STOCKTON FIRE STATION#12 <br /> Location 4010 E MAIN ST <br /> STOCKTON, CA 95205 <br /> Phone 209-937-8801 x <br /> Mailing Address 4010 E MAIN ST <br /> STOCKTON, CA 95205 <br /> Care of STOCKTON FIRE STATION#12 <br /> Location Code 99 - UNINCORPORATED P Alt Phone <br /> BOS District 002 - MILLER, KATHERINE Fax <br /> APN 15727514 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 AR0016794 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name Cj IfeD6p�rt nt (Circle one) <br /> Account Balance as of 2/251 15: $305.00 11 A\\) <br /> (Circle One) <br /> Transfer to Activellnaclve <br /> Program/Element and Description Record ID Employee ID and Name Status New Omen Delete <br /> 1921 -HMBP-Regular-Primary Location PR0539644 EE0000006-HAZA SAEED Active,l Y N A 1 D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PRO512082 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PRO509794 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2840-AST EXEMPT FAC <1,320 GAL PRO528824 EE0000005-FATINAH ZAREEF 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,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 certify that all operations will be performed in accordance with all applicable Ordinance Codes ander Standards and Slate 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 TRANSFERED: Amount Paid Date / I <br /> Payment Type Check Number Receive by i <br /> REHS: Date 2 7.�/�� Account out: Date <br /> COMMENTS: <br />