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Date run 4/18/2016 8:14:11AIV SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 4/18/2016 <br />Record Selection Criteria: Facility ID FA0023395 <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />OWNER FILE INFORMATION Number of facilities for this owner: 20 SSN / Fed Tax ID <br />Owner ID <br />OW0008853 Case Number: H08879 New Owner ID <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 />FA0023395 <br />Facility Name <br />SJC PUBLIC WORKS/UTILITY - FLAG CITY <br />Location <br />ryl <br />LODI, CA 95242 <br />Phone <br />Mailing Address <br />1702 E SCOTTS AVE <br />STOCKTON, CA 95205 <br />Care of <br />GUZMAN, BEN <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 />Alt Phone <br />Fax <br />EMail <br />Account ID AR0043111 <br />Mail Invoices to Facility Mail Invoices to: <br />Account Name SJC PUBLIC WORKS/UTILITY - FLAG CITY WELL # <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 />Transferto Active/Inactve <br />Program/Element and Description Record ID Employee ID and Name Status New Owner.? Delete <br />1926 - HMBP-Unstaffed Network Location PR0540896 EE0008709 - JAMIE DE LA ROSA Active Y N A I D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, anr/or project specific, PHS/EHD hourly charges associated with this facility or <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 State 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 <br />EHD Staff: U11\& Date / / Account out: XC6F Date <br />COMMENTS: <br />Invoice #: <br />