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Date run 12/13/2017 1:43:59P SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by DONNA Pagel <br /> - Facility Information as of 12/13/2017 <br /> Record Selection Criteria: Facility ID FA0010789 <br /> ` Make changes/corrections in RED Ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORATION Number of facilities for this owner: 1 SSN/Fed Tax ID <br /> Owner ID OW0008789 08754 New Owner ID <br /> .�stnerName DOVE <br /> Owner DBA CHARTER WAY TOW(AURORA) <br /> OwnerAddress 1234 S AURORA ST <br /> STOCKTON, CA 95206 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-339-8456 <br /> Mailing Address 1234 S AURORA ST <br /> STOCKTON, CA 95206 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0010789 10183821 <br /> Facility Name CHARTER WAY TO A) <br /> Location 1234 S AURORA ST <br /> STOCKTON, CA 95206 <br /> Phone 209-948-8500 xO <br /> Mailing Address 1234 S AURORA ST <br /> STOCKTON, CA 95206 <br /> Care of Rodney F Dove <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 001 -VILLAPUDUA, CARLOS Fax <br /> APN 15134023 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 AR0017789 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name CHARTER WAY TOW(AURORA) (Circle One) <br /> Account Balance as of 12/13/2017421-8Q, 1.-tea,° <br /> (Circle One) <br /> Transfer to Acivellnal <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner! Delete <br /> 1920-HMBP-Common Materials PR0521245 EE0009817-ROBERT LOPEZ Active Y N A D <br /> 2220-SM HW GEN<5 TONSNR PR0540982 EE0000026-CESAR RUVALCABA Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PR0513077 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE FI PR0510789 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGI PR0532259 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,anNor project speck,PHS/EHD hourly charges associated wM this facility <br /> or activity will be billed to the party identilled as the OWNER on this form. I also certify that all operations will be performed in accordance withal[applicable Ordinance Codes aril Standards and State anclix <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 Rece' eA-4 <br /> EHD Staff: Date Account out: Date <br /> COMMENTS: <br /> Oc>J,-pec' tx�net� 1�ove �o--dos �e C,�o�ccE lnvoire#: <br />