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Date run 5/2/2016 10:57:26AN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 5/2/2016 <br /> Record Selection Criteria: Facility ID FA0005180 <br /> Make changes/corrections in RED ink. Z <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 2 SSN/Fed Tax ID <br /> Owner ID OW0013211 New Owner ID <br /> Owner Name VERNON TRANSPORTATION <br /> Owner DBA VERNON TRANSPORTATION <br /> Owner Address 2313 W NAVY DR <br /> STOCKTON, CA 95206 <br /> Home Phone 209-546-0171 <br /> Work/Business Phone 209-546-0171 <br /> Mailing Address PO BOX 31450 <br /> STOCKTON, CA 95213 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0005180 10181761 <br /> Facility Name VERNON TRANSPORTATION <br /> Location 2313 W NAVY DR <br /> STOCKTON, CA 95206 <br /> Phone 209-546-0171 JA <br /> Mailing Address PO BOX 31450 <br /> STOCKTON, CA 95213 <br /> Care of <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOIS District 001 -VILLAPUDUA, CARLOS Fax <br /> APN 16332005 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name /� ' <br /> � r I L ��� *� �'� I t�y <br /> Title /tel• <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION �J /� lip <br /> Account ID AR0005628 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name VER SPORTATION (Circle One) <br /> Account Balance as of 5/212010 ---� I t� $ D <br /> �J 1 T— <br /> Ci cle 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 PR0528778 EE0009817-ROBERT LOPEZ Active Y N AOI D <br /> 2381 -UST FACILITY(BEFORE 1/84)-obsolete PR0501664 EE0000418-MICHAEL KITH Inactivs Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0533058 Inactivc Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1,the undersigned owner,operator or agent of same,acknowledge that all site,and'or project specific,PHSIEHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this form. lasso certify Nat all operations will be performed in accordance with all applicable Ordinance Codes andtor Standards and State endlor <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water Systeto be TRANSFERED: Amount Paid Date <br /> Payment Ty Check Number. Received by <br /> EHD Staff: Z Date�_/ /_ Account out: Date <br /> COMMENTS: p rC�CL_ <br /> / Invoice#: <br /> 5 <br /> S Ylo � � ofd rrA'IMp �� �� Ct�osS �o wti Lo <br />