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Date run 12/8/2017 2:26:08Ph SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 12/8/2017 <br /> Record Selection Criteria: Facility ID FA0022476 <br /> Make changestcorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID <br /> Owner ID OW0019912 New Owner ID <br /> Owner Name George Lackey <br /> Owner DBA <br /> OwnerAddress 44 N SAN JOAQUIN ST 590 <br /> STOCKTON, CA 95202 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-468-8912 <br /> Mailing Address 44 North San Joaquin Street <br /> Stockton, CA 95202 <br /> Care of FACILITIES MANAGEMENt OFFICE <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0022476 10586797 <br /> Facility Name San Joaquin County Administration Building <br /> Location 44 N SAN JOAQUIN ST <br /> Stockton, CA 95202 <br /> Phone 209-468-8912 x <br /> Mailing Address 44 North San Joaquin Street <br /> Stockton, CA 95202 <br /> care of George Lackey <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 001 -VILLAPUDUA, CARLOS Fax <br /> APN 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 AR0041139 NewAcceunt ID: <br /> Mail lnvoicesto Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name San Joaquin County Administration Building (Circle One) <br /> Account Balance as of 12/8/2017: $0.00 <br /> (Circle One) <br /> Transfer to ActiveJlnactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1920-HMBP-Common Materials PRO539307 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,anter project specific,PHS/EHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this farm. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes andfor Standards and State anclor <br /> Federal Laws. <br /> APPLICANT'S 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 Received by <br /> EHD Staff: Date_/ / Account out: Date <br /> COMMENTS: Invoice#: <br />