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Date run 4/19/2016 12:44:12PP SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report #5021 <br />Run by Pagel <br />Facility Information as of 4/19/2016 <br />Record Selection Criteria: Facility ID FA0017738 <br />OWNER FILE INFORMATION Number of facilities for this owner <br />Owner ID <br />OW0014563 <br />Owner Name <br />A.M. Stephens Const. Co., Inc. <br />Owner DBA <br />AM STEPHENS CONST CO INC <br />OwnerAddress <br />1717 S STOCKTON ST <br />Account Name A.M. Stephens Const. Co., Inc. <br />LODI, CA 95240 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />209-333-0136 <br />Mailing Address <br />P.O. Box 1867 <br />LODI, CA 95241 <br />Care of <br />(Circle One) <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID <br />FA0017738 10186667 <br />Facility Name <br />A M STEPHENS CONST CO INC <br />Location <br />1717 S STOCKTON ST <br />Delete <br />LODI, CA 95240 <br />Phone <br />209-333-0136 x <br />Mailing Address P.O. BOX 1867 <br />LODI, CA 95241 <br />Care of A.M. Stephens Construction Co., Inc. <br />Location Code 02 - LODI <br />Bos District 004 - WINN, CHARLES <br />APN 06219023 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />SSN / Fed Tax ID <br />New Owner ID : <br />Alt Phone <br />Fax <br />EMail : <br />Account ID AR0030945 <br />New Account ID: <br />: <br />Mail Invoices to Account <br />Mail Invoices to: Owner / <br />Facility / <br />Account <br />Account Name A.M. Stephens Const. Co., Inc. <br />(Circle One) <br />Account Balance as of 4/19/2016: $0.00 <br />(Circle One) <br />///jjj <br />Transfer to <br />Active/Inactve <br />,From Epment and Description Record ID <br />`L <br />Employee ID and Name Status <br />New Owner? <br />Delete <br />YH(� MBP -Regular -Primary Location PR0527520 <br />EE0008709 - JAMIE DE LA ROSA Active <br />Y N <br />A I D <br />2220 - SM HW GEN <5 TONS/YR PR0538575 <br />EE0001422 - ARIS VELOSO Active <br />Y N <br />A I D <br />4740 - WASTE TIRE SITE - EXEMPT PR0526216 <br />EE0004680 - NATALIA SUBBOTNIKOVA Active <br />Y N <br />A I D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARGE PR0532114 <br />Inactive <br />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 <br />will be performed in accordance with all applicable Ordinance Codes and/or Standards <br />and State andror <br />Federal Laws. <br />APPLICANT'S SIGNATURE: <br />Date <br />Program Records to be TRANSFERED: ' $25.00 = Amount Paid Date <br />Water System to be TRANSFERED: Amount Paid Date <br />Payment Ty e , Check Number Received by <br />EHD Staff: ��_ Date / /Account out: Date LI( <br />COMMENTS: <br />b5iI I I Invoice #: <br />