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Date run _d/11/2014 8:49:46AR SAN JO/ IN COUNTY ENVIRONMENTAL HEAL' DEPARTMENT RewdY5021 <br /> Run by 1w/ Paget <br /> Facility Information as of 4/11/2014 <br /> RecuN Selection Criteria: Facility ID FA0020341 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) .l3 <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID <br /> OwnerlD OW0016699 New Owner ID <br /> Owner Name Jg%fjV+6-V-GATT-G ahS -. Gsc4-f- <br /> Owner DBA CODE 3 CLEANERS <br /> Owner Address 1588 E MARCH LN <br /> STOCKTON, CA 95210 <br /> Home Phone zsiz�j sg o - z1f-LAI' <br /> Work/Business Phone 209-952-6333 <br /> Mailing Address �.� 2 1 Sz,, -L- lff> '. <br /> .e.k�he r cA CJS zo 6s, <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0020341 10,187,567 <br /> Facility Name CODE 3 CLEANERS <br /> Location 1588 E MARCH LN <br /> STOCKTON, CA 95210 <br /> Phone 209-952-6333 x0 <br /> Mailing Address $ LF-5z7 .5;0 . 44, �✓f <br /> GA 9S z o a. <br /> Care of <br /> Location Code 01 - STOCKTON Alt Phone <br /> BOS District 002 - RUHSTALLER, LARRY Fax <br /> APN 09614022 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 AR0036328 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name MARVIS V GATTO (Circle one) <br /> Account Balance as of 4/11/2014: $320.00 <br /> (Circle One) <br /> Transfer to Active/Inactye <br /> Program/Element and Description Record ID Employee IO and Name Status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PR0535226 EE0006044-LOWELL ALLEN Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO535291 Inactiv( Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent W same,acknowledge that all site,anclor 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 perlooned in accordance with all applicable Ordinance Codes andor Standards and State andor <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: I E'_Cl.�-TYX✓l ' 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 Re ve y <br /> REHS: Date / / e6t Account out: Date <br /> COMMENTS: <br />