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Date run 11/17/2017 3:21:54P SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 11/17/2017 <br />Record Seledion Criteria: Facility ID FA0010535 <br />OWNER FILE INFORMATION Number of facilities for this owner: 1 <br />Owner ID OW0008535 Case Number: H08290 <br />Owner Name <br />Owner DBA <br />Owner Address 2.605 TFFpFF [)R <br />Home Phone jfjef} <br />Work/Business Phone-209:7t67-880f�-- <br />Mailing Address <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID/CERS ID FA0010535 <br />Facility Name <br />Location 2601 TEEPEE DR <br />STOCKTON, CA 95205 <br />Phone Qgg grg$� <br />Mailing Address 2601 TEEPEE DR <br />STOCKTON, CA 952052421 <br />Care of <br />Location Code 99 - UNINCORPORATED A <br />BOS District 002 - MILLER, KATHERINE <br />APN 092-210-35 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION I <br />Account ID AR0017535 I 2- <br />Mail Invoices to Owner <br />Account Name ES M <br />Account Balance as of 11/17/2017: $0.00 <br />Make changes/corrections in RED ink. �7i <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />SSN /Fed Tax ID <br />New Owner In <br />fnAtMaV-N G' la!,gl L" <br />C -r p�r unn✓t i k.r. 6,A �-�snC- <br />'. <br />r awe <br />Alt <br />Alt Phone <br />Fax <br />atr,Fni <br />y I— v - <br />New Account ID: <br />Mail Invoices to: Owner / Facility / Account <br />(Circle One) <br />(Circle One) <br />Transfer to ActiveMadve <br />Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br />1921 - HMBP-Reqular-Primary Location PR0520405 EE0009817 - ROBERT LOPEZ Inactive Y N ; ry I D <br />2220 - SM HW GEN <5 TONS/YR PR0514368 EE9999996 - THREE VACANT3 Inactive Y N `j 1 D <br />2224 - HAZ MAT BUSINESS PLAN AUTHORIZATION PRO512823 EE9999996 - THREE VACANT3 Inactive Y N A I D <br />2399 - UNIFIED PROGRAM FAC STATE SURCHARGE FI PR0510535 EE0000000 - HAZ MAT SJC DES Inactive Y N A I D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operatoror agent of same, acknowledge that all site, ander protect 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 certgy that all operations will be performed in accordance with all applicable Ordinance Codes anNor Standards and State andor <br />Federal Laws. <br />APPLICANTS 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 -,7- Check Number Received by J <br />EHD Staff: 1(— 1 � - -C- -�-- Date -1 it /L/ij - Account out: Date <br />COMMENTS: ' `/ Invoice #: 3D,79L <br />