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Date run 8/25/2016 2:09:57PK SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 8/2512016 <br /> Record Selection Criteria: Facility ID FA0023617 <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 1 Fed Tax ID <br /> Owner ID OW0021917 New Owner ID <br /> Owner Name Government Properties Trust c/o The RMR Gr <br /> Owner DBA <br /> Owner Address <br /> Home Phone Not Specified <br /> Work]Business Phone 916-444_8710 <br /> Mailing Address 915 L Street, Suite 1250 <br /> Sacramento, CA 95814 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0023617 10486969 <br /> Facility Name Universal Facility#103 <br /> Location 603 SAN JUAN AVE <br /> STOCKTON, CA 95203 <br /> Phone 916-444-8710 x <br /> Mailing Address 915 L Street, Suite 1250 <br /> Sacramento, CA 95814 <br /> Care of Government Properties Trust c/o The RMR Gr <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0043641 New Account ID: ; <br /> Mail Invoices to Account Mail Invoices to: Owner I Facility I Account <br /> Account Name Anshu Bera (Circle One) <br /> Account Balance as of 8/25/2016: $0.00 <br /> (Circle Cne} <br /> Transfer to Activellnactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Reqular-Primary Location PRO541227 EE0009817-ROBERT LOPEZ Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andlor project specific,PHSIEHD hourly charges associated with this facility <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 andlor Standards and State andlor <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date I I <br /> Program Records to be TRANSFERED: *$25.00= Amount Paid Date 1 1 <br /> Water System to be TRANSFERED: Amount Paid Date ! 1 <br /> Payment Type Check Number Received b <br /> EHD Staff: Date 1 1 Account out: bV�2 Date 1�j2—q 11 140 <br /> COMMENTS: Invoice#: ';7 /�✓'� <br /> t fe,c,,4eil iil i�y <br /> C. k C41n Gig S <br />