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Date run 1/20/2017 10:52:01Af SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 1/20/2017 <br />Record Selection Criteria: Facility ID FA0023839 <br />OWNER FILE INFORMATION Number of facilities for this owner: 1 <br />Owner ID OW0022229 <br />Owner Name ADM -SPECIALTY COMMODITIES INC <br />Owner DBA <br />Owner Address <br />Home Phone Not Specified <br />Work/Business Phone 209-932-8132 <br />Mailing Address 861 PERFORMANCE DR <br />STOCKTON, CA 95206 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID <br />FA0023839 10710841 <br />Facility Name <br />SCI Stockton <br />Location <br />861 Performance Dr <br />Stockton, CA 95206 <br />Phone <br />209-932-8132 x <br />Mailing Address <br />861 PERFORMANCE DR <br />STOCKTON, CA 95206 <br />Care of <br />ADM -SPECIALTY COMMODITIES, INC. <br />Location Code <br />BOS District <br />APN <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0044167 <br />Mail Invoices to Account <br />Account Name ADM -SPECIALTY COMMODITIES INC <br />Account Balance as of 1/20/2017: $0.00 <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 />Mail Invoices to: <br />New Account ID: : <br />Owner / Facility / Account <br />(Circle One) <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 PR0541585 EE0009817 - ROBERT LOPEZ Active Y N A I D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, andror project specific, PHS/EHD hourly charges associated with this facility or e <br />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 Slate and/or 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 Type Check Number Received by <br />EHD Staff: a. M Date / 4) Account out: Date <br />COMMENTS: <br />Invoice #: <br />C rem -10 MW fA c�titv�. and �PY�oSy 155 , B LII (� U�m v�ni �S <br />