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Date run 8/18/2017 9:48:25AK SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#W21 <br /> Pagel <br /> Run by <br /> Facility Information as of 8/1812017 <br /> Record Selection Chrome: Facility ID FA0016552 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) 7� <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID <br /> Owner ID OW0013407 New Owner ID <br /> Owner Name BARAJAS, GRISELDA <br /> Owner DBA CORONA PM ROAD SERVICE <br /> OwnerAddress 1887 E 11TH ST <br /> STOCKTON, CA 95206 <br /> Home Phone 209-495-0768 <br /> Work/Business Phone 209-932-0598 <br /> Mailing Address 2327 MARIPOSA RD <br /> STOCKTON, CA 95205 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0016552 10185189 <br /> Facility Name CORONA PM ROAD SERVICE <br /> Location 2327 MARIPOSA RD <br /> STOCKTON, CA 95205 <br /> Phone 209-932-0598 X <br /> Mailing Address 2327 MARIPOSARD <br /> STOCKTON, CA 95205 <br /> Care of Griselda Barajas <br /> Location Code Alt Phone <br /> BOIS District Fax <br /> APN 17129016 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name Grlselda Barajas <br /> Title Owner <br /> Day Phone 209-932-0598 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0029189 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name CORONA PM ROAD SERVICE (CirdeOne) <br /> Account Balance as of 8/18/2017: $0.00 <br /> (CimJe One) <br /> Transfer to Acthnslnac e <br /> Program/Elermanl and Description Record ID Employee ID and Name Status New Owner! Delete <br /> 1921 -HMBP-Regular-Primary Location PR0524649 EED009817-ROBERT LOPEZ Active Y N A D <br /> 2228-GEN 25<50 TONS PERMIT PRO538510 EE9999996-THREE VACANT3 Active Y N A D <br /> 2831 -AST FAC >/= 1,320-<10 K GAL CUMULATIVE PRO541109 EE9999996-THREE VACANT3 Active Y N A D <br /> 4740-WASTE TIRE SITE-EXEMPT PR0524826 EE0000060-JENNIFER FRASE Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGI PRO531397 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all sSe,andor protect specific.PHSEHD hourly charges associated with this facility <br /> or active,will be billed to the party Well as the OWNER on this form. I also certify Nat all operations will be petlormed m accordance with all applicable Ordinance Codes andor Stands,,and State ander <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: Date / I <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to TRANSFERED: Amount Paid Date <br /> Payment Typa( Check Number Received b <br /> EHD Staff: Date 2/IF/L7 Account out: DateI�LI l <br /> COMMENTS: <br /> Invoice#: <br />