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Date run 2/12/2014 245:0017N SAN JOA IN COUNTY ENVIRONMENTAL HEAL' DEPARTMENT Report#6021 <br /> Run by t� •.00 Pagel <br /> Facility Information as of 2/12/2014 <br /> Record Selection Criteria. Facility ID FA0017488 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0014329 New Owner ID <br /> Owner Name EDWARD KING <br /> Owner DBA EDWARD KING <br /> Owner Address 18700 NIJOEL WAY <br /> STOCKTON, CA 95215 <br /> Home Phone Not Specified _ <br /> Work/Business Phone Not Specified <br /> Mailing Address 18700 NIJOEL WAY <br /> STOCKTON, CA 95215 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID 1 CERS ID FA0017488 10,186,523 <br /> Facility Name EDWARD KING <br /> Location 18700 NIJOEL WAY <br /> STOCKTON, CA 95215 <br /> Phone 209-467-1725 x0 -- - <br /> Mailing Address 18700 NIJOEL WAY <br /> STOCKTON, CA 95215 <br /> Care of <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 18502032 EMaL <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0030370 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility I Account <br /> Account Name EDWARD KIN, (Circle One) <br /> Account Balance as of 2/12/2014: $53,00 <br /> (Circle One) <br /> Transfer to Active'Inactve <br /> Program/Element and Description Record ID Employee CD and Name Status New Owner? Delete <br /> 1958-HM-Farm Operations PR0525673 Active Y N AD <br /> 2840-AST EXEMPT FAC < 1,320 GAL PR0530723 EE0000753-WILLY NG Active,! Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0534640 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT. I,the undersigned owner,operator or agent of same,acknowledge that all site,anti 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. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes anti Standards and State andfor <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date / 1 <br /> Program Records to be TRANSFERED: `$25.00= Amount Paid Date I 1 <br /> Water System to be TRANSFERED: Amount Paid Date 1 1 <br /> Payment Type Check Number Receive y <br /> REHS: \!'J, Date! t'—f 19 Account out: Date���/ <br /> COMMENTS: <br /> U_Z,,,p- ;,n CL J V-v - <br />