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.+1w <br /> Data win 10/25/2017 9:41:33A SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report 95021 <br /> Run by Pagel <br /> Facility Information as of 10!25/2017 <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 INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID <br /> Owner ID OW0008789 Case Number: H08754 New Owner ID <br /> Owner Name DOVE, RODNEY <br /> Owner DBA CHARTER WAY TOW(AURORA) <br /> Owner Address 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 lD/CERS ID FA0010789 10183821 <br /> Facility Name CHARTER WAY TOW (AURORA) <br /> Location 1234 S AURORA ST <br /> STOCKTON, CA 95206 <br /> Phone 209-948-8500 x0 <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 X - <br /> Day Phone <br /> Night Phone e SS p <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) (Cirde One) <br /> Account Balance as of 10/25/2017: $421.00 <br /> (Circle One) <br /> Transfer to Active/Inacive <br /> Progra"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 I D <br /> 2220-SM HW GEN<5 TONS/YR PRO540982 EE0000026-CESAR RUVALCABA Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PRO513077 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PRO510789 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO532259 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,anclor project specific,PHS/EHD hourly charges associated with this facility or; <br /> be billed to the party identified as the OWNER an this form. t also certify that all operations will be performed in accordance with all applicable Ordinance Codes andror Standards and State andror 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 Received by <br /> EHD Staff: Date / / Account out: Date-1-0 <br /> COMMENTS: <br /> 1 Invoice#: <br /> Mw. �tNoJ wo��rt SS Gkq -r— 48 Ptr t LTv---ri M. . <br />