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Date run 12/17/2015 9:05:44A SAN JOAQUIN COUNTY ENVIRONMENTAL HReport#5021EALTH DEPARTMENT Pagel <br /> Run by Facility Information as of 12/17/2015 <br /> Record Selection Criteria: Facility ID FA0019723 <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 SSNI Fed Tax ID <br /> Owner ID OW0016180 New Owner ID <br /> Owner Name LINCOLN UNIF SCH DIST <br /> Owner DBA LINCOLN UNIFIED SCHOOL DIST FM <br /> Owner Address 3122 BROOKSIDE RD <br /> STOCKTON, CA 95219 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-953-8585 <br /> Mailing Address 3122 BROOKSIDE RD <br /> STOCKTON, CA 95219 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0019723 10187367 <br /> Facility Name LINCOLN UNIFIED SCHOOL DIST FMC <br /> Location 3122 BROOKSIDE RD <br /> STOCKTON, CA 95219 <br /> Phone 209-953-8585 x0 <br /> Mailing Address 3122 BROOKSIDE RD <br /> STOCKTON, CA 95219 <br /> Care of Brian Tillman <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 003- BESTOLARIDES, STEVE Fax <br /> APN 11806017 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 AR0035085 New Account ID: <br /> Mail Invoices to: Owner / Facility / Account <br /> Mail Invoices to Owner <br /> CiUeOne) <br /> Account Name LINCOLN UNIF SCH DIST <br /> Account Balance as of 12/17/2015: $0.00 (Circle One) <br /> Transfer to Activellnactse <br /> ProgmMElement and Description <br /> Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PR0529886 EE0000006-HAZA SAEED cove f Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0533221 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,angor project specific,PHSIEHD hourly charges associated with thisfacility <br /> or activity will be billed to the party identified as the OWNER on this term. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes anclor Standards and State andbr <br /> Federal Laws. <br /> APPLICANTS 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 b)f <br /> EHD Staff: _ <br /> Date__­l_L­ Account out: Date�l l�� <br /> COMMENTS: Invoice#: <br />