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Date mn 10/7/2014 12:13:58PI SAN JOAQUI N COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Rapon N50I1 <br /> Run by 1273 Paget <br /> Facility Information as of 10/7/2014 <br /> Record Selection Criteria: Facility ID FA0021388 <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 NAW 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 ID/CERS ID FA0021388 10187853 <br /> Facility Name VERNON TRANSPORTATION INC <br /> Location 2225 NAVY DR <br /> STOCKTON, CA 95203 <br /> Phone 209-546-0171 x <br /> Mailing Address PO BOX 31450 <br /> STOCKTON, CA 95213 <br /> Care of Vernon Transportation Company <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 001 -VILLAPUDUA Fax <br /> APN 16331004 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 AR0038753 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name VERNON TRANSPORTATION INC (Circle one) <br /> Account Balance as of 10/7/2014: $0.00 <br /> (Circle One) <br /> Transfer to Active/InacNe <br /> Program/Element and Description Record ID Employee ID and Name Status New Omer? Delete <br /> 1925-HMBP-Multisite Secondary Location PRO537262 EE0009817-ROBERT LOPEZ 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 protect specific,PHS/EHD howdy charges associatetl with this facility <br /> or activity will be client t�party identifiedd�sass ththheOWNER,py s form I also t�Ne,al��tions wiI? Manned in�ca enra with)all applicable Ordinance Codes andor Standards and State ardor <br /> Federal Laws, 1 /T it a�✓ / [' , IJJ' -a ltJ ✓•/+ JLp0�/�iJ/s <br /> APPLICANTS SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Check Number Recei e <br /> REHS: Date_/ / Account out: <br /> COMMENTS: <br />