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Date run 2/4/2C*5 11:11:30AM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 2/4/2015 <br /> Record Selection criteria: Facility ID FA0005287 <br /> Make changeslcorrections In RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 2 SSN/Fed Tax ID <br /> Owner ID OW0015119 New Owner ID <br /> Owner Name DELTA TRANSPORT INC <br /> Owner DBA <br /> Owner Address 15135 W EIGHT MILE RD <br /> STOCKTON, CA 95219 <br /> Home Phone 925-890-5099 <br /> Work/BusinessPhone 209-951-4634 <br /> Mailing Address 2321 CLINTON CT <br /> ANTIOCH, CA 94509 <br /> Care of JOHNSON, DAVID <br /> FACILITY FILE INFORMATION Site Mitigation Facility <br /> Facility lD/CERS ID FA0005287 10181789 <br /> Facility Name H & H MARINA <br /> Location 15135 W EIGHT MILE RD <br /> STOCKTON, CA 95219 <br /> Phone 209-951-4634 x 11A 1 <br /> Mailing Address 2321 CLINTON CT —Ll f <br /> ANTIOCH, CA 94509 <br /> Care of DELTA TRANSPORT INC <br /> Location Code 99- UNINCORPORATED P Alt Phone <br /> BOIS District 004-VOGEL, KEN Fax <br /> APN 06908021 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 AR0005748 New Account ID. <br /> Mail Invoices to Facility Mail Invoices to. Owner / Facility / Account <br /> Account Name H & H MARINA (circle One) <br /> Account Balance as of 2/4/2015: $1,270.50 <br /> (Circle One) <br /> Transfer to AuivellnacNe <br /> ProgramlElement and Description Record ID Employee ID and Name Status New Owneo Delete <br /> 1920-HMBP-Common Materials PRO519562 EE0008709-JAMIE DE LA ROSA Active Y N A 62 D <br /> 2220-SM HW GEN<5 TONS/YR PRO516679 EE0001422-ARIS VELOSO Inactive Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PRO511629 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2226-CalARP PROGRAM PR0514568 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2381 -UST FACILITY(BEFORE 1/84)-obsolete PR0501969 EE0000418-MICHAEL KITH Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PR0509341 EE0000000-HAZ MAT SJC OES Inactive Y N A /ll , D <br /> 2832-AST FAC 10 K-</=100 K GAL CUMULATIVE PR0516678 EE0001422-ARIS VELOSO Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0532787 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andor project speck,PHSIEHD hourly charges associated with this facility <br /> or activity will be billed to the parry identeried as the OWNER on this form I also certify that all operations will be performed in accordance with all applicable Ordinance Codes ander Standards and State arida <br /> Federal Laws. <br /> S NAY fav FE Q�� l .T. NAX T Au o`^X'� 'lb O0PL <br /> ADSInST tn=F C_4Av-rh S 12_44A &E fNl.1/k91-E PE Tl OSz <br /> APPLICANTS SIGNATURE: ' Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date / ID <br /> Water System to be TRANSFERED: Amount Paid Date / I <br /> Payment Type Check Number Receiv d b <br /> REHS: !A.tJ Date__2__ / / Account out: U15 Date -2- 1 <br /> COMMENTS: <br />