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Date run 10/15/2014 9:26:31A SAN JOAQUIN COU2J L VIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run byPagel <br /> Facility Information as of 10/15/2014 <br /> Racord Selection Cdt9da: Facility ID FA0020330 <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 OW0016691 New Owner ID <br /> Owner Name J & H MARINE <br /> Owner DBA <br /> Owner Address 2040 SAN ESTEBAN CIR <br /> ROSEVILLE, CA 95747 <br /> Home Phone 209-992-2958 <br /> Work/Business Phone 209-951-0283 <br /> Mailing Address 2040 SAN ESTEBAN CIR <br /> ROSEVILLE, CA 95747 <br /> Care of KOSTER, ERIC <br /> FACILITY FILE INFORMATION <br /> Facility ID I CERS ID FA0020330 10187555 <br /> Facility Name J & H Marine <br /> Location 401 N SAN JOSE ST <br /> STOCKTON, CA 95203 <br /> Phone 209-951-0283 x <br /> Mailing Address 401 N SAN JOSE ST <br /> STOCKTON, CA 95203 <br /> Care of KOSTER, ERIC <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 001 -VILLAPUDUA Fax <br /> APN 13526016 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name ERIC KOSTER <br /> Title OWNER <br /> Day Phone 209-951-0283 <br /> Night Phone 209-992-2958 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0036311 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name J & H Marine (CirdeOne) <br /> Account Balance as of 10/15/2014: $155.00 T/ 1 <br /> L_ , a` l l °'vn ` X82' <br /> � ( /rL (Circle One) <br /> Transfer to ActivaAnadve <br /> Program/Element and Description Record ID Employee ID and Name Status New 0.0 Delete <br /> 1920-HMBP-Common Materials PR0539537 EE0000006-HAZA SAEED Active Y N A I D <br /> 2222220..-33M HW GEN<5 TONS/YR PRO535168 EE0009488-JEFFREY WONG Active Y N A D <br /> C_ dULAST FAC >/=1,320-<to K GAL CUMULATIVE PRO535169 EE0009488-JEFFREY WONG —A;W6.1r Y N A b <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0535170 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,enNor project specific,PHSIEHD hourly charges associated with Mis facility <br /> or activity will be blued 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 andor Standards and State andor <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date I / <br /> Water System to be TRANSFERED: Amount Paid Date <br /> / 14—CPayment Type Check Number -Recry <br /> y <br /> REHS: Date 1461101DAL Account out: Date=/-3-14— <br /> COMMENTS: <br /> OMMENTS: <br />