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1. <br />Datern 10/21/2015 9:30:47A SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 10/21/2015 <br />Record Selection Criteria: Facility ID FA0014402 <br />OWNER FILE INFORMATION Number of facilities for this owner <br />Owner ID <br />Owner Name <br />Owner DBA <br />Owner Address fi(e)f 7 iA <br />Home Phone <br />Work/Business Phone_NlGt_F�_ <br />Mailing Address 4aB...�8_... <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID FA0014402 <br />Facility Name ;_' , ERG pE+lr <br />Location 4250 E MARIPOSA RD <br />STOCKTON, CA 95215 <br />Phon <br />Mailing Address <br />Care of <br />Location Code 99 - UNINCORPORATED A <br />BOS District 004 - WINN, CHARLES <br />APN 17956020 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />1 <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 />L. • ■`TJi7lIA• <br />Fax <br />EMail: <br />SMA� i. <br />.• L I <br />Account ID AR0024482 <br />New Account ID: <br />Mail Invoices to Owner <br />Mail Invoices to: Owner / <br />Account Name <br />Account Balance as of 10/21/2015: $0.00 <br />Program/Element and Description Record ID <br />Employee IID and Name Status <br />1921 - HMBP-Regular-Primary Location PR0519260 <br />EEOOIJ A= �P�- Inactive <br />2800 - ABOVEGROUND STORAGE TANK (AST) PROGF PRO528053 <br />EE0001421 - STACY RIVERA Inactive <br />Facility / Account <br />(Circle One) <br />(Circle One) <br />Transfer to Active/Inactve <br />New Owner? Delete <br />Y Nl' I D <br />Y N 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 and/or Standards and Stale anclior <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 Typ Check Number Received by <br />EHD Staff: Date-0/�L/_ Account out: V -t) Date /I / <br />COMMENTS: <br />(U� �� 0 �6 � S Invoice # <br />