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Date run 10/2/2014 10:24:14AI SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report M21 <br /> Run by Pagel <br /> Facility Information as of 10/2/2014 <br /> Record Selection Criteria: Facility ID FA0005180 <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: 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 <br /> Mailing Address PO BOX 31450 <br /> STOCKTON, CA 95213 <br /> Care of <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 001 -VILLAPUDUA Fax <br /> APN 16332005 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 AR0005628 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name VERNON TRANSPORTATION (Circle One) <br /> Account Balance as of 10/2/2014: $0.00 <br /> (Circle One) <br /> Transfer to Actwellmi <br /> Progrem/Element and Description Record ID Employee ID and Name Status New Owner! Delete <br /> 1921 -HMBP-Regular-Primary Location PRO528778 EE0009817-ROBERT LOPEZ Active Y N A 9 D <br /> 14"M11 GEN 5<25 TONS PERMIT PRO528547 EE0001421 -STACY RIVERA Active Y N A D <br /> 23 1-UST FACILITY(BEFORE 1/84)-obsolete PRO501664 EE0000418-MICHAEL KITH Inactivc Y N A I D <br /> 7ERAST FAC 10 K-</=100 K GAL CUMULATIVE PR0528315 EE0001421 -STACY RIVERA Active Y N A I D <br /> WASTE TIRE SITE-EXEMPT PR0524344 EE0009000-HARPRIT MATTU Active Y N A I D <br /> -ELECTRONIC REPORTING STATE SURCHARG PRO533058 Inactive Y N A 1 0 <br /> 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 /> y will be billed to the paM identified as the OWNER onthis form. I also certify Nat all operations will be performed in accordance with all applicable Ordinance Codes andtor Standards and State andor <br /> Laws2s41D due I� , 145 �ak�6ns P&SR U9U10-tt Ca-pac)r CANTS SIGNATURE: Datem Records to be TRANSFERED: '$25.00= Amount Paid DateSystem to be TRANSFERED: Amount Paid Date /nt TypCheck Number Received by <br /> Date�v / 2 / Account out: DateNTS: PQ O5'2it -t44)an �Qo52s�y �> and Pa052.8315 -to T;roo21as& dbit e t0 a paj 41a- <br /> d, fAOU'-fLoV1 o¢ +VU -&aL4'+Lj - zv1aci'rvat2 X2052s1 8- 'F/1 aefi�itfeo cr�ir noO <br /> uhLC( y ad-4� 222s Xavy Ar. <br />