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Date run 2/22/2017 2:41:30PK SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 2/22/2017 <br />Record Selection Criteria: Facility ID FA0017956 <br />OWNER FILE INFORMATION Number of facilities for this owner : 1 <br />Owner ID <br />OW0014752 <br />Owner Name <br />ROSS ISLAND SAND & GRAVEL CO <br />Owner DBA <br />ROSS ISLAND SAND & GRAVEL CO <br />OwnerAddress <br />409 EMBARCADERO ST <br />Status <br />STOCKTON, CA 95203 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />503-239-5504 <br />Mailing Address <br />PO BOX 82249 <br />Active <br />PORTLAND, OR 97282-0249 <br />Care of <br />I D <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID FA0017956 10186729 <br />Facility Name ROSS ISLAND SAND & GRAVEL CO <br />Location 409 EMBARCADERO ST BLDG 16 <br />STOCKTON, CA 95203 <br />Phone 503-239-5504 x <br />Mailing Address PO BOX 82249 <br />PORTLAND, OR 97282-0249 <br />Care of Ross Island Sand & Gravel Co. <br />Location Code <br />BOS District 003 - BESTOLARIDES, STEVE <br />APN 16203007 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Make changestcorrections in RED ink. <br />INFORMATION CHANGE (date) Z 7 7 <br />OWNERSHIP CHANGE (date) <br />SSN / Fed Tax ID <br />New Owner ID : <br />Alt Phone <br />Fax <br />EMail : <br />Account ID AR0031489 <br />Mail Invoices to Account <br />Account Name ROSS ISLAND SAND & GRAVEL CO <br />Account Balance as of 2/22/2017: $675.00 <br />Program/Element and Description Record ID Employee ID and Name <br />New Account ID: : <br />Mail Invoices to: Owner / Facility / Account <br />(Circle One) <br />1921 - HMBP-Reqular-Primary Location PR0526515 EE0009817 - ROBERT LOPEZ <br />2220 - SM HW GEN <5 TONS/YR PR0538594 EE0001421 - STACY RIVERA <br />ERSC - ELECTRONIC REPORTING STATE SURCHARGI PR0531495 <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 and/or Standards and State and/or <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 Check Number Received by <br />EHD Staff: Z Date Z /14 / 17 Account out: Date 7 <br />COMMENTS: <br />Ir1V01Ce #: <br />C � <br />VV\a- <br />�C,S V, <br />(Circle One) <br />Transfer to <br />Active/Inactve <br />Status <br />New Owner? <br />Delete <br />Active <br />Y N <br />A <br />I D <br />Active <br />Y N <br />A <br />I D <br />Inactive <br />Y N <br />A <br />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 and/or Standards and State and/or <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 Check Number Received by <br />EHD Staff: Z Date Z /14 / 17 Account out: Date 7 <br />COMMENTS: <br />Ir1V01Ce #: <br />C � <br />VV\a- <br />�C,S V, <br />