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Date run 5/17/2017 12:03:19PI SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 5/17/2017 <br />Record Selection Criteria: Facility ID FA0017245 <br />OWNER FILE INFORMATION Number of facilities for this owner <br />Owner ID <br />OW0014086 <br />Owner Name <br />JERRY ATKINS <br />Owner DBA <br />JERRY ATKINS <br />Owner Address <br />12332 E HWY 26 <br />STOCKTON, CA <br />95215 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />209-481-2727 <br />Mailing Address <br />12332 E HWY 26 <br />STOCKTON, CA <br />95215 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID <br />FA0017245 <br />10186141 <br />Facility Name <br />JERRY ATKINS <br />Location <br />12332 E HWY 26 <br />STOCKTON, CA <br />95215 <br />Phone <br />209-481-2727 x <br />Mailing Address <br />12332 E HWY 26 <br />STOCKTON, CA <br />95215 <br />Care of <br />Jerry Atkins <br />Location Code <br />BOS District <br />APN <br />10318007 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0030127 <br />Mail Invoices to Account <br />Account Name JERRY ATKINS <br />Account Balance as of 5/17/2017: $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 />New Account ID: : <br />Mail Invoices to: 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 />-j( 1958 - HM -Farm Operations PR0525430 EE0002670 - MUNIAPPA NAIDU Active Y N A gD <br />2220 - SM HW GEN <5 TONS/YR PR0530274 ✓ EE0000031 - ELIANNA FLORIDO Active Y N A D <br />2830 - AST FAC - SPCC EXEMPT PR0530273 EE0009488 - JEFFREY WONG Inactive Y N A `�D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARG PR0531958 Inactive Y N A I D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENTI, 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 and/or <br />Federal Laws. <br />APPLICANT'S SIGNATURE: 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: Date 5 /tel / Account out: 146 Date <br />COMMENTS: <br />J teeA 1 / ill Invoice #: <br />