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Date mn , /2015 4:51:58PM SAN JO*IN COUNTY ENVIRONMENTAL HEA#DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 319/2015 <br /> Record Selection Criteria: Facility ID FA0014264 <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 Arc k <br /> Owner ID OW0011318 New Owner ID : �r M <br /> Owner Name DELTA EQUIPMENT {)B� <br /> Owner DBA DELTA EQUIPMENT INC CO KtzawmY>SE�JJ <br /> Owner Address 4901 E MARIPOSA <br /> STOCKTON, CA 95205 / R5 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-464-1323 <br /> Mailing Address 4901 E MARIPOSA RD <br /> STOCKTON, CA 95215 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0014264 <br /> Facility Name DELTA EQUIPMENT <br /> Location 4901 E MARIPOSA <br /> STOCKTON, CA 95205 <br /> Phone 209-464-1323 x0 <br /> Mailing Address 4901 E MARIPOSA RD ( <br /> STOCKTON, CA 95215 <br /> Care of <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 17906007 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account 10 AR0024217/ New Account ID: <br /> Mail Invoices to O err A—1 Mail Invoices to: Owner / acilit / Account <br /> Account Name DELTA EQUIPMENT (Circle One) <br /> Account Balance as of 3/9/2015: $0.00 <br /> (Circle One) <br /> Transferto AcgveMaclve <br /> Progran✓Element and Description Record ID Employee ID and Name Status New Omen Delete <br /> 1921 -HMBP-Regular-Primary Location PRO520353 EE0000000-HAZ MAT SJC OES Inactive Y N I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PRO519062 EE0000000-HAZ MAT SJC OES Inactive Y N jj I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PR0519063 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PR0524435 EE0007379-AMANDA BOERTIEN Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andor project specific,PHS/EHD hourly charges associated with this facility <br /> or activity will be billed to the parry identified as the OWNER on this forml also certify that all operations will be performed in accordance with all applicable Ominance Codes ander Standards and State andor <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date I / <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type /Che k Number Received by <br /> REHS: - ate-�?—/ /-4Z Account out: Date <br /> COMMENTS: <br />