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Date run 8/14/2018 3:09:42PN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 8/14/2018 <br />Record Selection Criteria: Facility ID FA0009754 <br />Make changes/corrections 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 OW0007754 New Owner ID <br />Owner Name MERRY X RAY CHEMICAL CORP <br />Owner DBA MERRY X-RAY CHEMICAL CORP <br />Owner Address 1045 NATIONAL DR 9 <br />SACRAMENTO, CA 958341930 <br />Home Phone Not Specified <br />Work/Business Phone 916-928-0450 <br />Mailing Address 1045 NATIONAL DR STE 9 <br />SACRAMENTO, CA 95834-1930 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID/CERS ID FA0009754 10182871 <br />Facility Name MERRY X-RAY CHEMICAL CO INC <br />Location 711 N SAN JUAN AVE <br />STOCKTON, CA 95203-1420 <br />Phone 916-928-0450 x A L4 <br />Mailing Address 1045 NATIONAL DR STE 9 <br />SACRAMENTO, CA 95834-1930 <br />Care of Merry X -Ray Chemical Corporation <br />Location Code Alt Phone <br />BOS District Fax <br />APN 13336035 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 AR0016754 New Account ID: <br />Mail Invoices to Account Mail Invoices to: Owner / Facility / <br />Account <br />Account Name MERRY X-RAY CHEMICAL CO INC (Circle One) <br />Account Balance as of 8/14/2018: $0.00 <br />(Circle One) <br />Transferto <br />Active/Inactve <br />Program/Element and Description Record ID Employee ID and Name Status New Owner? <br />Delete <br />1921 - HMBP-Reqular-Primary Location PR0521020 EE0009817 - ROBERT LOPEZ Active Y N <br />AD <br />2220 - SM HW GEN <5 TONS/YR PR0514022 EE0001421 - STACY RIVERA Active Y N <br />A D <br />2224 - HAZ MAT BUSINESS PLAN AUTHORIZATION PR0512042 EE0000000 - HAZ MAT SJC OES Inactive Y N <br />A I D <br />2399 - UNIFIED PROGRAM FAC STATE SURCHARGE FI PR0509754 EE0000000 - HAZ MAT SJC OES Inactive Y N <br />A I D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARGI PR0534528 Inactive Y N <br />A I D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, and/or project specific, PHS/EHD 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 andror Standards <br />and State and/or <br />Federal Laws. <br />APPLICANT'S SIGNATURE: Date <br />Program Records to be TRANSFERED: ' $25.00 = Amount Paid Date <br />Water System to be TRANSFERED: Amount Paid Date <br />Payment Type Check Number Received b <br />EHD Staff: Date Account out: _ y/ Date <br />COMMENTS: <br />Invoice #: <br />0 <br />