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Date run 1118/2017 3:20:45PN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 11/8/2017 <br /> Record Selection Criteria: Facility ID FA0000355 <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: 12 SSN 1 Fed Tax ID <br /> Owner ID OW0000049 New Owner ID <br /> Owner Name ESCALON UNIFIED SCHOOL DISTRIC <br /> Owner DBA ESCALON UNIFIED SCHOOL DISTRIC <br /> OwnerAddress 1520 E YOSEMITE AVE <br /> ESCALON, CA 953201753 _- <br /> Home.Phone 209-838-3591 <br /> Work/Business Phone 209-838-3591 <br /> Mailing Address 1520 E YOSEMITE AVE <br /> ESCALON, CA 95320-1753 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility IDICERS ID FA0000355 10180579 <br /> Facility Name EUSD-VAN ALLEN SCHOOL <br /> Location 21051 E HWY 120 <br /> ESCALON, CA 95320 - - <br /> Phone 209-838-2931 x <br /> Mailing Address 1520 E YOSEMITE <br /> ESCALON, CA 95320 <br /> Care of ESCALON UNIFIED SCHOOL DIST <br /> Location Code 99- UNINCORPORATED A Alt Phone <br /> BOS District 004 -WINN, CHARLES Fax <br /> APN 20525004 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 AR0000354 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner I Facility I Account <br /> Account Name EUSD-VAN ALLEN SCHOOL (Circle One) <br /> Account Balance as of 1118!2017: $172.00 <br /> (Circle One) <br /> Transfer to Activellractve <br /> ProgramlElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1632-EXEMPT FOOD PRO161696 EE0004589-KADEANNE LINHARES Active Y N A I D <br /> 1920-HMBP-Common Materials PR0523311 EE0000009-NICHOLAS LOEHRER Active Y N A I D <br /> 2381 -JST FACILITY(BEFORE 1184)-obsolete PRO504484 EE0007289-ALISON YOUNGBLOOD Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGI PRO534246 Inactive Y N A I D <br /> 4630-NTNC WATER SYSTEM WA0461167 EE0000003-VANCE WONG Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOVIA-EDGEMENT. I,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. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes ancl'or Standards and State andfor <br /> Federal Laws_ <br /> APPLICANT'S SIGNATURE: Date 1 1 <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date / 1 <br /> Water System to be TRANSFERED: Amount Paid Date 1 1 <br /> Payment Type Check Number Received by <br /> EHD Staff: Date 1 I Account out: Date 1 1 <br /> COMMENTS: <br /> Invoice#: <br />