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Date run 3/20/2017 4:52:41 PN Run by SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Facility Information as of 3/20/2017 I Record Selection Criteria: Facility ID FA0013563 OWNER FILE INFORMATION Number of facilities for this owner: 19 Owner ID OW0009441 Owner Name DEPT OF AGING Owner DBA 2736 TEEPEE DR C OwnerAddress PO BOX 201056 Phone STOCKTON, CA 95202 Home Phone 209-933-0657 Work/Business Phone 209-851-8370 Mailing Address PO BOX 201056 Location Code STOCKTON, CA 95202 Care of JOHNSON, JANICE FACILITY FILE INFORMATION Facility ID / CERS ID FA0013563 10184411 Facility Name SJC COMMODITY PROGRAM Location 2736 TEEPEE DR C STOCKTON, CA 95205 Phone 209-468-3679 x Mailing Address PO BOX 201056 STOCKTON, CA 95201 Care of SENIOR NUTRITION PROGRAM Location Code 99 - UNINCORPORATED A Bos District 002 - MILLER, KATHERINE APN 13208003 EMERGENCY NOTIFICATION CONTACT INFORMATION Contact Name DAN ORTIZ Title Day Phone 209-468-2202 Night Phone ACCOUNTS RECEIVABLE FILE INFORMATION Report #5021 Pagel Make changestcorrections in RED ink. / y INFORMATION CHANGE (date) / OWNERSHIP CHANGE (date) SSN / Fed Tax ID New Owner ID : Alt Phone Fax EMail : Account ID AR0022672 Mail Invoices to Facility Mail Invoices to: Account Name SJC COMMODITY PROGRAM Account Balance as of 3/20/2017: $0.00 New Account ID: : Owner / Facility / Account (Circle One) (Circle One) Transfer to Active/Inactve Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete 1632 - EXEMPT FOOD PR0517717 EE0009488 - JEFFREY WONG AY N A I D 1920 - HMBP-Common Materials PR0521057 EE0009817 - ROBERT LOPEZ I Ive 1 Y N I D 2399 - UNIFIED PROGRAM FAC STATE SURCHARGE FI PR0519211 EE0001084 - STEPHANIE RAMIREZ Inactive Y N I D ERSC - ELECTRONIC REPORTING STATE SURCHARGI PR0533347 Inactive Y N A I D 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 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 and/or Standards and State anclor Federal Laws. APPLICANT'S SIGNATURE: Date / ! Program Records to be TRANSFERED: * $25.00 = Amount Paid Date Water System to TRANSFERED: Amount Paid Date Payment Typ Check Number Received by �7 EHD Staff: Date l 26 / Account out: 65 Date COMMENTS:%1455 Invoice #: