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Date run 4/18/2016 8:27:04AN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by <br />4 % Facility Information as of 4/18/2016 Pagel <br />Record Selection Criteria: Facility ID FA0010373 <br />OWNER FILE INFORMATION Number of facilities for this owner : 20 <br />Owner ID <br />OW0008853 Case Number: H08879 <br />Owner Name <br />SAN JOAQUIN COUNTY <br />Owner DBA <br />PUBLIC WORKS <br />OwnerAddress <br />1810 E HAZELTON AVE <br />STOCKTON, CA 95205 <br />Home Phone <br />209-468-3057 <br />Work/Business Phone <br />209-468-3090 <br />Mailing Address <br />1702 E SCOTTS AVE <br />STOCKTON, CA 95205 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID <br />FA0010373 10183493 <br />Facility Name <br />SJC PUBLIC WORKS /UTILITY (PRIMARY) <br />Location <br />1702 E SCOTTS AVE <br />STOCKTON, CA 95205 <br />Phone <br />209-468-3090 x <br />Mailing Address <br />1702 E SCOTTS AVE <br />STOCKTON, CA 95205 <br />Care of <br />GUZMAN, BEN <br />Location Code <br />01-STOCKTON <br />BOS District <br />001 - VILLAPUDUA, CARLOS <br />APN <br />15507014 <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 />SSN / Fed Tax ID <br />New Owner ID <br />Xe-$-6u%-M"- 9-3010 <br />Alt Phone <br />Fax <br />EMail : <br />Account ID AR0017373 <br />Mail Invoices to Account Mail Invoices to <br />Account Name SJC PUBLIC WORKS/ UTILITY (PRIMARY) <br />Account Balance as of 4/18/2016: $0.00 <br />New Account ID: : <br />Owner / Facility / Account <br />(Circle One) <br />(Circle One) <br />Transfer to Activennactve <br />II/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br />X26—HMBP-Unstaffed Network Location PR0512661 EE0000006 - HAZA SAEED Active Y N A I D <br />2220 - SM HW GEN <5 TONS/YR PR0517914 EE0009488 - JEFFREY WONG Inactive Y N A I D <br />2399 - UNIFIED PROGRAM FAC STATE SURCHARGE FE PR0510373 EE0000000 - HAZ MAT SJC OES 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, 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 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 Tye Check Number Receive by <br />EHD Staff: �YV i_�_ Date / / Account out: Date <br />COMMENTS: <br />IDVOICe #: <br />