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------------------- ------------------------ - ------------------------- --- -1------------------------------ - ------------------------------- ----------------- --. - -- -------- <br /> Date run 8/15/2014 3:09:56PK SAN JO. JIN COUNTY ENVIRONMENTAL HEAL DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 8/15/2014 <br /> Record Selection Criteria: Facility ID FA0022530 <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: 1 SSN/Fed Tax ID <br /> Owner ID OW0020068 New Owner ID <br /> Owner Name San Joaquin County <br /> Owner DBA <br /> Owner Address <br /> Home Phone Not Specified <br /> Work/Business Phone 209-468-3099 <br /> Mailing Address 444 S. Wilson Way <br /> Stockton, CA 95205 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0022530 10588471 <br /> Facility Name Fleet Services- Hospital/Park South <br /> Location 500 W Hospital Rd <br /> French Camp, CA 95231 <br /> Phone 209-468-3099 x <br /> Mailing Address 444 S. Wilson Way <br /> Stockton, CA 95205 <br /> Care of San Joaquin County Fleet Services <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 19305010 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 AR0041210 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name Fleet Services- Hospital/Park South (Circle One) <br /> Account Balance as of 8/15/2014: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1920-HMBP-Common Materials PR0539419 EE0002474-MICHAEL PARISSI Active Y N A I D <br /> 2831 -AST FAC >/=1,320-<10 K GAL CUMULATIVE PR0539420 EE0002646-THUY TRAN Active 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 withal[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 Rec i by <br /> REHS: t/ Date /�4/ l Account out: Date <br /> COMMENTS: <br /> Ck-( -S <br /> lNv �,5�3ot. I <br />