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Date nm Report#5021 <br /> 10/15/2014 9:26:54A SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Pagel <br /> Run by `Facility Information as of 10/15/2014 <br /> Record Selection Cntena: Facility ID FA0013653 <br /> Make changesicorrections 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 OW0010763 Maw owner ID <br /> Owner Name KOSTER, ERIC <br /> Owner DBA J & H MARINEb <br /> owner Address 401 N SAN JOSE ST `S 4-06 <br /> STOCKTON, CA 95203-2631 - r7- r Q AS�lrl—f <br /> Home Phone 209-951-0283 <br /> Work/Business Phone Not Specified <br /> Mailing Address 401 N SAN JOSE ST - <br /> STOCKTON, CA 95203-2631 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA001365310184489 <br /> Facility Name J & H MARINE <br /> Location 401 N SAN JOSE ST <br /> STOCKTON, CA 95203-2631 <br /> Phone 209-951-0283 <br /> Mailing Address 401 N SAN JOSE ST <br /> STOCKTON, CA 95203-2631 <br /> Care of <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 001 -VILLAPUDUA Fax <br /> APN 13526016 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION LL <br /> Contact Name <br /> Title <br /> Day Phone Z o <br /> Night Phone if <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0022810 New Account ID: <br /> Mail lnvoicesto FBCIIIty Mail Invoices to: Owner / FacilRy / Account <br /> Account Name J & H MARINE ime ne) <br /> Account Balance as of 10/15/2014: $0.00 <br /> (circle One) <br /> Transfer to Activefinactve <br /> ProgramrElement and Description Record ID Employee ID and Name Status New Owne/ Delete <br /> 1921 -HMBP-Regular-Primary Location PRO518012 EE0009817-ROBERT LOPEZ Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PRO518011 EE0009488-JEFFREY WONG Inactive Y N® I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PRO518013 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andor project spadgc,PHSIEHD hourly charges associated with this family <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 ander Standards and State andor <br /> Federal Laws. <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 Re ce' y <br /> REHS: Date/—z5--/�. Account out: Date=1=14— <br /> / /4- <br /> COMMENTS: 1 n TT <br /> kkAr*0?6-/ $Sf�r/� !S tom-) ie^5� f•. 0, <br /> 11'-" DV ;� .Dr. r4 -C,—, <br /> W� / p llt � '1^�-, 1.4'-1 F—P OD 33 0 <br />