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Date run 12/23/2015 4:02:15P SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report #5021 <br />Run by IbrOWn Pagel <br />Facility Information as of 12/23/2015 <br />Record Selection Criteria: Facility ID FA0013992 <br />Make changestcorrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />OWNER FILE INFORMATION Number of facilities for this owner: 1 <br />SSN / Fed Tax ID <br />Owner ID OW0011072 <br />New Owner ID <br />Owner Name CITY OF STOCKTON <br />Owner DBA <br />Owner Address 6 E LINDSAY <br />STOCKTON, CA 95202 <br />Home Phone 209-937-8372 <br />Work/Business Phone 209-937-8285 <br />Mailing Address 6 E LINDSAY <br />STOCKTON, CA 95202 <br />Care of CHRIS MORENO/SHANE MCAFFEE <br />FACILITY FILE INFORMATION �i S -P-qq7 <br />0 <br />Facility ID / CERS ID FA0013992 <br />Facility Name WEBER EVENT CTR INTERACTIVE FOUNT <br />Location 221 N CENTER q16 <br />;2-3 7� <br />, <br />STOCKTON, CA 95202 <br />Phone 209-937-8372 <br />Mailing Address 6 E LINDSAY <br />STOCKTON, CA 95202 <br />Care of CHRIS MORENO/SHANE MCAFFEE <br />Location Code 01 - STOCKTON <br />Alt Phone <br />BOS District 001 - VILLAPUDUA, CARLOS <br />Fax <br />APN-139OGG 8' I M o q o o ( <br />EMail: <br />EMERGENCY NOTIFICATION CONTACT INFORMATION ; <br />I Po(."/lsd's <br />Contact Name CHRIS MORENO/SHANE MCAFFEE <br />`�}DG�' a n 6-�T 'zs�zzI' <br />Title <br />Day Phone 209-937-8372 <br />Night Phone 209:937-8285 <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0023671 <br />Mail Invoices to Facility Mail Invoices to: <br />Account Name WEBER EVENT CTR INTERACTIVE FOUNTAI <br />Account Balance as of 12/23/2015: $0.00 <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 />3633 - INTER -ACTIVE FOUNTAIN - EXEMPT PR0518593 EE0003361 - MARIBEL FLOHRSCHUTZ 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 with all applicable Ordinance Codes and/or Standards and State andlor <br />Federal Laws. <br />4tk 1q2/ (��p5`f0(aSZ <br />APPLICANT'S SIGNATURE: Date <br />Program Records to be TRANSFERED: <br />Water System to be TRANSFERED: <br />Payment Type Check Number <br />EHD Staff: <br />COMMENTS: <br />' $25.00 = <br />Date <br />Amount Paid Date <br />_ Amount Paid Date <br />Received y <br />Account out: <br />Invoice #: <br />°„".,l add/L.t_� II Cis <br />