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Data ran 6/16/2014 12:25:45PI SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> Report#5021 <br /> Pages <br /> Ran by Facility Information as of 6/16/2014 <br /> Record Selection Criteria: Facility ID FA0020330 <br /> Make changeslcorrections in RED ink. 77 <br /> / INFORMATION CHANGE(date) /O � y' c...P <br /> l51 OWNERSHIP CHANGE(date) <br /> OWNER FILE IN ORMATION Number of facilities for this ow r: 1 SSN/Fed Tax ID <br /> Owner ID OW0016691 New Owner ID : <br /> Ow er Name 0.�l&p <br /> er DBA <br /> C g0 S <br /> Owner ddress kzcy-,F 7—F IrrR QMLV I <br /> Home hone 2DS "oma— <br /> Work/Business one Not Specified <br /> Mailing A ess <br /> Gs o c(e- <br /> Car of <br /> FACILITY FILE INFORM A ION <br /> Facility ID/CERS I FA0020330 10187555 -� <br /> f\ / \QVy/LQ <br /> Facility Name <br /> Location 01 N S JOSE ST <br /> S OCK N, CA 95203 <br /> Phone � 8' 3 <br /> Mailing Address 401 AN JOSE ST <br /> STO KION, CA 95203 <br /> Care of FA JOSEPH <br /> Location Code 0 -S OCKTON Alt Phone _ <br /> BOS District 1 -V LAPUDUA Fax <br /> APN 35260 6 EMail: _? r. L _ mck P-V ,"d) 1 <br /> EMERGENCY NOTIFICAT ON CONT A T INFORMATION <br /> Contact N e s"[c k a ste.r <br /> itle <br /> Day hone _ _ Q�/— /9 2 $ 3 <br /> Nig Phone <br /> ACCOUNTS REC VABLE FILE INFORM TION <br /> Account ID AR0036311 New Account ID: <br /> it Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name DELTA MARINE S RVICES INC ` ZQ ��GJ (clrcb One) <br /> Account B ance as of 6116/2014: $0.00 J �d �r't Pc( / M Aircle y 0.we) <br /> Transfer to Active/InacNe <br /> PrograME enl and Description Record ID Employee ID and Name Status New Owner? Delete <br /> elete <br /> 222 -SM HW GEN<5 TONSNR PR0535168 EE0009488-JEFFREY WONG Active Y N A p/ D <br /> 2831-AST FAC >/=1,320-<10 K GAL CUMULATIVE PRO535169 EE0009488-JEFFREY WONG Active,l Y N A D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0535170 Inactive Y N A D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the urMersigned owner,operator or agent of same,acloi ladae that ail site,andor project speougc,PHSEHD hourly charges associated with Mus facility <br /> oractivity will be billed to the party identified as the OWNER on this form I also certify that all operations wili be performed in accordance w'th all applicable mance Codes andor Standards and State ands <br /> Federal l4'ao =t' 'v 6 3` ,637 �N v#a61 � 5 — ��I t u V *��ra�t o <br /> APPLICANTS SIGNATURE: Date / / <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRAN FERED: Amount Paid Date I / <br /> Payment Type Pheck Number Receiv d <br /> REHS: Date / / Account out: Date <br /> COMMENTS: � <br />