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Date run 9/21/2017 2:0428Pry SANT JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> Run by Report#5021 <br /> Facility Information as Of 9/21/2017 Pagel <br /> Record Selee ian Criteria: Facility ID FA0019859 <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 OW0016289 New Owner ID <br /> Owner NamennnRTl <br /> Owner DBA <br /> Owner Address 16849 6ALVESTE)lf-V� <br /> STOCKTON, CA 95209Y- 210 <br /> Home Phone-209-684-44f.9- <br /> Work/Business Phone Not Specified <br /> Mailing Address <br /> 64:E)6KTQl1j, GA 9153299 l <br /> Care of TCI T N� <br /> I <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0019859 10187395 <br /> Facility Name TPI I o;! ell ITn ROG'( llilk-yn rDat y- <br /> Location 1807 E CHEROKEE RD STE 1 &2 <br /> STOCKTON, CA 95205 <br /> Phone <br /> Mailing Address ' �� I�� hC�'1l1 <br /> Care of <br /> Location Code 99- UNINCORPORATED A Alt Phone <br /> BOS District 002 - MILLER, KATHERINE Fax <br /> APN 11910003 EMaiI: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> ContactName-ALI G ^A <br /> Title <br /> Day Phone -2g9._47G_2e6 ---- <br /> Night Phone- �— <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0035373 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name (� _{.. A�,,`�� (Circle One) <br /> Account Balance as of 9/21/2017: $2,224.50 — m6ua 10 /'tkD&C 5-13 <br /> (Cirde One) <br /> Transfer to Activellnact. <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2220-SM HW GEN<5 TONSNR PRO530489 EE9999996-THREE VACANT3 Active Y N A I D <br /> 3122-STORMWATER INSPECTION-AUTO SHOP PRO530490 EE0009488-JEFFREY WONG Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGI PRO534345 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the untlersigned owner,operator or agent of same,acknowledge that all site,and'or projed speciflo PHSEHD hourly charges asso rated 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 andor Standards and State andor <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 Ty Check Number Received <br /> EHD Staff: .1 Date / /1: Account out: Date - <br /> COMMENTS: <br /> 0 <br /> tick) bli,6 NZ CL� 4N5 _ ' (U Invoice#: <br />