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Date run 1/29/2018 12:10:52PI SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report 7/5021 <br /> Run by Pagel <br /> Facility Information as of 1/29/2018 <br /> Record Selection Criteria: Facility ID FA0002435 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) DI(act -LD 115 <br /> OWNERSHIP CHANGE(date) m r Oh ),.201 <br /> OWNER FILE INFORMATION Number of facilities for this owner: 5 SSN/Fed Tax ID <br /> Owner ID OW0001860 New Owner ID : <br /> Owner Name DELTA BLOOD BANK LLC Tine flmP lrlXn �P CrbSS <br /> Owner DBA <br /> OwnerAddress 65 N COMMERCE ST <br /> STOCKTON, CA 95202 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-943-3830 <br /> Mailing Address 3131 N VANCOUVER AVE <br /> PORTLAND, OR 97227-1560 ^� <br /> Care of DELTA BLOOD BANK INC <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0002435 10180929 <br /> Facility Name DELTA BLOOD BANK `ChA 1Y1C�I( G;h x-nsc <br /> Location 65 N COMMERCE ST <br /> STOCKTON, CA 95202 <br /> Phone 209-943-3830 x <br /> Mailing Address PO BOX 800 <br /> STOCKTON, CA 95201 <br /> Care of DELTA BLOOD BANK —I fYleTic-P, n P CDsS <br /> Location Code 01 - STOCKTON Alt Phone <br /> BOS District 001 -VILLAPUDUA, CARLOS Fax <br /> APN 13728012 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name ELAYDA PODESTA <br /> Title COMPLIANCE OFFICER nl 0. <br /> Day Phone 209-943-3830 x220 ;;l D4 — ,2 S -7 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0004593 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name (Cirde One) <br /> Account Balance as of 1/29/2018: $1,340.30 <br /> (Circle One) <br /> Transferto AcGveAnactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner! Delete <br /> 1921 -HMBP-Regular-Primary Location PR0530821 EE0009817-ROBERT LOPEZ Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PR0518109 EE0001421 -STACY RIVERA Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE FI PR0518110 EE9999998-ONE VACANTI Inactive Y N A I D <br /> 4530-LG QUANITY GENERATOR PRG450112 EE0003973-ROBERT MCCLELLON Active Y N A 1 D <br /> 4557-MED WASTE LIMITED HAULER PRO506421 EE0003973-ROBERT MCCLELLON Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGE PRO531672 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 specific,PHS/EHD hourly charges associated with this facility <br /> or activity will be billed to the party ident6ied as the OWNER on this form. I also candy that all operations will be performed in accordance with all applicable Ordinance Codes ancior Standards and State and'or <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: ---7/©gwt�G�S/JL.Y�c- Date L2Ll ag / 20/8 <br /> - <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Check NumberReceived b f/ <br /> EHD Staff: Date / Q/ Account out: Date <br /> COMMENTS: <br /> IDVOICe#: <br />