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Date run 6/16/2014 12:25:45PI SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Pagel <br /> Run by Facility Information as of 6/16/2014 <br /> Record Selection Criteria: Facility ID FA0020330 <br /> Make changes/corrections in RED Ink. <br /> ` r INFORMATION CHANGE(date) 6 <br /> lA OWNERSHIP CHANGE(date) <br /> OWNERFILEIN 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 /> er DBA -70L4iLJ C a S /(t <br /> Owner ddress �ncEVl�7—�yfA 4c'7r-1 r7 <br /> Home hone 2^D "ari 4444 <br /> Work/Business one Not Specified <br /> Mailing A ess <br /> s oc(clavf <br /> Car of F `TiYr G kG.o,s ✓- <br /> FACILITY FILE INFORMA ION <br /> Facility ID/CERS I FA0020330 10187555 -� <br /> d 1-1 1�0.V1/�Q <br /> Facility Name <br /> Location 01 N S JOSE ST <br /> S OCK N, CA 95203 <br /> Phone - 7 $r3 <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 Eli: r (-- _ AMC ii-X CQ)m <br /> EMERGENCY NOTIFICAT ON CONTA T INFORMATION ))/� <br /> Contact N e Si"C C (_ash,-r <br /> itle <br /> Day hone gg9_q$1.1d1� �j/— n 2 $ 3 <br /> Nig Phone <br /> ACCOUNTS REC VABLE FILE INFORM TION <br /> Account ID ARO 036311 D New Account ID: <br /> it Invoices to Facility t}�iw""'� Mail Invoices to: Owner / Facility / Account <br /> Account Name DELTA MARINE S RVICES INC 9 Z� /fL t (Circle one) <br /> Account B ance as of 6/16/2014: $0.00 C7r 1 t3 <br /> F" �d oL �Y� CJ �r ' _ lC <br /> � irdeO� <br /> Transferto Actiwlnactm <br /> ProgramlE ant and Description Record ID Employee ID and Name Status New Owner? /Delete <br /> 222 -SM HW GEN<5 TONS/YR PR0535168 EE0009488-JEFFREY WONG Active Y N A 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: 1,the undersigned owner,operator or agent of same,acknowledge that ell site,andfor Project speck,PHSrEHD hourly charges associated with this facility <br /> or adiv,tywill be billed to the party identified as the OWNER m this form I also certify that all operations will be performed in accordance w'th all applicable oninanoi,Codes and'or Standards and State ands <br /> Federal Laws t q`949 - )PkI9 5 3`75. `� N�#a519k �3 - I I t A! V IA)�7a3l O <br /> APPLICANT'S SIGNATURE: `fit `Jf Date Il <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date if <br /> Water System to be TRAN FERED: Amount Paid Date I / <br /> Payment Type A heck Number Recent d <br /> REHS: Date_/ / Account out: Date, /f <br /> COMMENTS <br />