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Date sm ET12/2017 4:54:52PK SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENTRepoli M21 <br /> Run of Pagel <br /> Facility Information as of 6/12/2017 <br /> Record Selection Criteria: Facility ID FA0009932 <br /> Make changestcorrections in RED ink. (7 <br /> INFORMATION CHANGE(date) r <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID <br /> Owner ID OW0016111 New Owner ID <br /> Owner Name DE .✓ <br /> Owner DBA _ I,�-A11n 10 L 1141, _ -41ilI C k / A•1t <br /> Owner Address•Per-�-- <br /> �. <br /> Home Phone Not Specified <br /> Work/Business Phone 2.Gq-462-54.Q() Z.Q <br /> MailingAddress ,{,r Iontl7lc, <br /> fl S'2-p \� <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0009932 10183041 <br /> Facility Name +Z .r <br /> Location 1001 W CHARTER WAY <br /> STOCKTON, CA 95206 <br /> Phone. <br /> Mailing Address g /( 0 p / (�• _ moi' �....c�y <br /> F r.t rpm. u�nNAp (ten ��m�— ci 6 • _� -n �_� �Y.��/� �/ <br /> Care of <br /> Location Code 01 - STOCKTON Alt Phone <br /> BOS District 001 -VILLAPUDUA, CARLOS ^(6� Fax <br /> APN 16323043 ` Entail <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION 0 <br /> Contact Name ViV <br /> Title Y ' <br /> Day Phone 00 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> i <br /> Account ID AR0016932 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name (Circle One) <br /> Account Balance as of 6/12/20 : $1,045.50 <br /> (Girds One) <br /> Transfer to Activer7nacene <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Reqular-Primary Location PRO519968 EE0009817-ROBERT LOPEZIna Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PRO512220 EE0000000-HAZ MAT SJC OES till Y N ID <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE FI PR0509932 EE0000000-HAZ MAT SJC OES Inactive Y N I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGI PRO532846 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOW-E DGEMENT: I,the undersgned owner,operator or agent of same,atlmowledge that all site,anNor project specific,PHSiEHD hourly charges associated with this facility <br /> or activM will be billed to the party identified as the OWNER on this form. I also candy that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and State and/or <br /> Federal Lewis <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date / / <br /> Water System to TRANSFERED: Amount Paid Date <br /> Payment Typef Check Number Received y <br /> EHD Staff: 7 Date 1�l� 1 Account out: Date j 7 <br /> COMMENTS: <br /> Invoice#: -21LI419 ' <br />