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Date run 10/14/2015 9:50:02A SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 10/14/2015 <br />Record Selection Criteria: Facility ID FA0017042 <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 <br />Owner ID <br />OW0013883 <br />Owner Name <br />ROD DEMENT <br />Owner DBA <br />ROD DEMENT <br />Owner Address <br />3761 BROOK VALLEY CIR <br />STOCKTON, CA 95219 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />Not Specified <br />Mailing Address <br />3761 BROOK VALLEY CIR <br />STOCKTON, CA 95219 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID FA0017042 10185799 <br />Facility Name ROD DEMENT <br />Location 1725 S HOLT RD <br />STOCKTON, CA 95206 <br />Phone 559-469-5146 x0 <br />Mailing Address 3761 BROOK VALLEY CIR <br />STOCKTON, CA 95219 <br />Care of <br />Location Code <br />BOS District <br />APN 13106005 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0029924 <br />Mail Invoices to Owner <br />Account Name ROD DEMENT <br />Account Balance as of 10/14/2015: $505.00 <br />SSN / Fed Tax ID <br />New Owner ID : <br />Alt Phone <br />Fax _ <br />EMail : <br />Mail Invoices to <br />New Account ID: : <br />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 />1958 - HM -Farm Operations PR0525227 EE0009817 - ROBERT LOPEZ Active Y N A ® D <br />2220 - SM HW GEN <5 TONS/YR PR0530933 EE0001421 -STACY RIVERA Active Y N A D <br />2830 - AST FAC - SPCC EXEMPT PR0530932 EE0001421 - STACY RIVERA Active Y N A D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARG PRO532245 Inactive Y N A I D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, andlor 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 />i <br />APPLICANT'S SIGNATURE:J, 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 b <br />EHD Staff: d✓1 /V�z ✓% tDate I o l /c/ /—LC-- Account out: 6a=Date / / T <br />COMMENTS: <br />Invoice #: <br />