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Date ran 6/16/2014 12:25:45PI SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report 11,5021 <br /> Run by Facility Information as of 6/16/2014 Paget <br /> Record Selection Criteria: Facility ID FA0020330 y�r <br /> Make changes/corrections in RED Ink. <br /> INFORMATION CHANGE(date) <br /> 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 <br /> O erDBA ST0.r(�g/A' <br /> f <br /> Owner <br /> ddress cevl &,rA <br /> Home hone 2.09-4Z4_1414— G1 2-- Z9 <br /> Work/Business one Not Specified <br /> Mailing A ass 446awtel <br /> D C(C1'n7 <br /> Car of F rTi r1 G '�GO,S -V' <br /> FACILITY FILE INFORMA ION <br /> Facility ID/CERS I FA0020330 10187555 d M ca N//lQ <br /> Facility Name <br /> Location 01 N S JOSE ST <br /> S OC N. CA 95203 <br /> Phone <br /> Mailing Address 401 AN JOSE ST <br /> STO KTON, 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 Entail: e ri. L Ma ( 4j -dw t <br /> EMERGENCY NOTIFICAT ON CONTA T INFORMATION <br /> Contact N e j i G ic e sf� p-r• <br /> itle <br /> Day hone <br /> Nig Phone <br /> ACCOUNTS REC VABLE FILE INFORM TION <br /> Account ID AR0036311 New Account ID: <br /> illnvoicesto Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name DELTA MARINES RVICES INC �w (Circle One) <br /> Account B ance as of 6/16/2014: $0.00E <br /> CAS.2d L.X ck- e' yq <br /> Transfer Ate <br /> ProgranvE mentand Description Record ID Employee ID and Name Status New Owner? Delle <br /> 222 -SM HW GEN<5 TONSNR PR0535168 EE0009488-JEFFREY WONG Active Y N A I D <br /> 2831 -AST FAC >/=1,320-<10 K GAL CUMULATIVE PR0535169 EE0009488-JEFFREY WONG Active,l Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0535170 Inactivf Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknomedge that all site,and'or project specific,PH&EMD hourly charges associated with this facility <br /> or activity will be billed to the party identified as Ne OWNER on this form IaI also certify that all operations will be performed in accordance th all applicable cIrtimance Codes andior Stand rEe and State encV <br /> Federal Lawn(iy� = t Ai V � �a�t o <br /> APPLICANT'S SIGNATURE: 1 Date I / <br /> Program Records to be TRANSFERED: •$25.00= Amount Paid Date <br /> Water System to be TRAN FERED: Amount Paid Date / /_ <br /> Payment Type heck Number Receiv d y <br /> REHS: Date_/ / Account Out: Date��l / <br /> COMMENTS: 71V s ^FA,,,5?5 � <br />