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Date run 8/1/2018 1:33:23PM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 8/1/2018 <br /> Record Selection Criteria: Facility ID FA0009034 <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 <br /> Owner ID OW0007034 Case Number: H00505 New er ID <br /> Owner Name <br /> Owner DBA <br /> Owner Address <br /> STOCKTON, CA 95215 <br /> Home Phone 209-464-8701 <br /> Work/Business Phone 209-464-8701 <br /> Mailing Address 3030 S HWY 99 <br /> STOCKTON, CA 95215 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0009034 10182361 <br /> Facility Name <br /> Location <br /> STOCKTON, CA 95215 <br /> Phone 209-464-8701 x <br /> Mailing Addres <br /> 2,43 <br /> Care <br /> Location Code 99 - UNINCORPORATED A Alt Phone <br /> BOS District 001 -VILLAPUDUA, CARLOS Fax <br /> APN T74664 -7— ' -7_-1 SS02 `T/_ 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 AR0016034 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility ! Account <br /> Account Name GREEN MAN MATERIALS (Circle One) <br /> Account Balance as of 8/1/2018: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PR0520920 EE0008709-JAMIE LIMA Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PR0511322 EE0000000-HAZ MAT SJC IDES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE FE PR0509034 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PR0527340 EE0004486-ANGELICA SANDOVAL MARII Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGE PR0534745 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andlor 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 and/or Standards and State 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 <br /> Payment Typ Check Number Received by <br /> EHD Staff: ��l,Y��— Date / 1 / Account out: Date X / �! <br /> COMMENT'/S: �,y, �,��n <br /> Gr l � r�A A_ YU w0 `�� Invoice#: <br /> (o ax-h tri - nea) <br />