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Date ma '8/13/2018 11:57:31AP SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report #5021 <br />Rur: by <br />Pagel <br />Facility Information as of 8/13/2018 <br />z <br />Record Selection Criteria: Facility ID FA0023839 <br />Make changestcorrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />OWNER FILE INFORMATION Number of facilities for this owner : 1 SSN / Fed Tax ID <br />Owner ID OW0022229 New Owner ID <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 FA0023839 10710841 <br />Facility Name SCI Stockton <br />Location 861 Performance Dr <br />Stockton, CA 95206 <br />Phone 209-932-8132 x <br />Mailing Address 861 PERFORMANCE DR <br />STOCKTON, CA 95206 <br />Care of ADM -SPECIALTY COMMODITIES, INC. <br />Location Code Alt Phone <br />BOS District Fax <br />APN EMail : <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 New Account ID: <br />Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br />Account Name ADM -SPECIALTY COMMODITIES INC (Circle One) <br />Account Balance as of 8/13/2018: $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-Reqular-Primary Location PR0541585 EE0009817 - ROBERT LOPEZ Active Y N A 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 andror <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 Type Check Number Received by Q� <br />EHD Staff: Date / / / �J Account out: Date / 7 i O <br />COMMENTS: <br />Invoice #: <br />