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Date run 4/18/2016 8:42:47AN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 Run by Pagel Facility Information as of 4/18/2016 Record Selection Criteria: Facility ID FA0010856 OWNER FILE INFORMATION Number of facilities for this owner: 20 Owner ID OW0008853 Case Number: H08879 Owner Name SAN JOAQUIN COUNTY Owner DBA PUBLIC WORKS Owner Address 1810 E HAZELTON AVE Delete STOCKTON, CA 95205 Home Phone 209-468-3057 Work/Business Phone 209-468-3090 Mailing Address 1702 E SCOTTS AVE 2224 HAZ MAT BUSINESS PLAN AUTHORIZATION STOCKTON, CA 95205 Care of FACILITY FILE INFORMATION Facility ID / CERS ID FA0010856 10183877 Facility Name SJC PUBLIC WORKS /UTILITY-HSPTL LIF Location MATHEWS RD & DELIVERY RD FRENCH CAMP, CA 95231 Phone 209-468-3090 x Mailing Address 1702 E SCOTTS AVE STOCKTON, CA 95205 Care of GUZMAN, BEN Location Code 99 - UNINCORPORATED P Bos District 001 - VILLAPUDUA, CARLOS APN 19305014 EMERGENCY NOTIFICATION CONTACT INFORMATION Contact Name Title Day Phone Night Phone ACCOUNTS RECEIVABLE FILE INFORMATION Make changes/corrections in RED ink. INFORMATION CHANGE (date) OWNERSHIP CHANGE (date) SSN/Fed Tax ID New Owner ID : Alt Phone Fax EMail : Account ID AR0017856 Mail Invoices to Account Mail Invoices to: Account Name SJC P IES MAINTENAN E DISTS Account Balance as of 4/18/201 $3_ d �� New Account ID: : Owner / Facility (Circle One) Account (Circle One) Transfer to Active/Inactve Element and tion m/HMBP-RegularP Reco Employee ID d Name Status Owner? Delete N 1 G Primary Location PR0539859 EE0000010 PETER LOMBARDI Active Y A 2224 HAZ MAT BUSINESS PLAN AUTHORIZATION PRO513144 EE0000000 - HAZ MAT SJC OES Inactive Y N A I D 2399 - UNIFIED PROGRAM FAC STATE SURCHARGE F PR0510856 EE0000000 - HAZ MAT SJC OES Inactive Y N A I D 2840 - AST EXEMPT FAC < 1,320 GAL PRO529102 EE0000753 - WILLY NG 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, PHS/EHD hourly charges associated 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 andor 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 EHD Staff: ��(V�� Date /��/� Account out: Date COMMENTS: Invoice #: