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Date run 6/16/2017 11:08:24AA SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report #5021 <br />Run by Pagel <br />Facility Information as of 6/16/2017 <br />Record Selection Criteria: Facility ID FA0019691 <br />OWNER FILE INFORMATION Number of facilities for this owner <br />Owner ID <br />OW0016148 <br />Owner Name <br />KMM Telecommunications <br />Owner DBA <br />KMM TELECOMMUNICATIONS <br />Owner Address <br />2136 PONY EXPRESS CT <br />Phone <br />STOCKTON, CA 95215 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />973-244-1380 <br />Mailing Address <br />9 Law Dr Ste 13 <br />Location Code <br />Fairfield, NJ 07004 <br />Care of <br />001 - VILLAPUDUA, CARLOS <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID <br />FA0019691 10187319 <br />Facility Name <br />KMM TELECOMMUNICATIONS <br />Location <br />2136 PONY EXPRESS CT <br />STOCKTON, CA 95215 <br />Phone <br />209-234-6841 x0 <br />Mailing Address <br />2136 Pony Express Ct <br />Stockton, CA 95215 <br />Care of <br />Cesar Felix <br />Location Code <br />01-STOCKTON <br />BOS District <br />001 - VILLAPUDUA, CARLOS <br />APN <br />17307028 <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 />1 SSN / Fed Tax ID <br />New Owner ID : <br />Alt Phone <br />Fax <br />EMail : <br />Account ID AR0035053 New Account ID: : <br />Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br />Account Name KMM TELECOMUNICATIONS (Circle One) <br />Account Balance as of 6/16/2017: $0.00 <br />(Circle One) <br />Transfer to Active/Inactve <br />Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br />1921 - HMBP-Regular-Primary Location PR0529854 EE0008709 - JAMIE LIMA Active Y N AD <br />2220 - SM HW GEN <5 TONS/YR PRO538558 EE0001421 - STACY RIVERA Inactive Y N A D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARGE PR0531656 Inactive Y N 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. PHSIEHD 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 ancl/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 e Check Number Received <br />EHD Staff: ` Date L10 / / 17 Account out: Date <br />COMMENTS: <br />Invnirn ik• <br />�3us��v� lis h LAZt2.. �ortc- Lr�. <br />