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Date run 5/24/2018 4:56:47PR SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report45021 <br /> Run by Facility Information as of 5/24/2018 Paget <br /> Record Selection Criteria: Facility ID FA0003806 <br /> Make changes/connections in RED ink. 2 <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Numberof facilities forthis owner: 1 SSN/Fed Tax ID : <br /> Owner ID OW0002822 New 0wjerlD <br /> Owner Named _,S4WSpN_GQ__W (.J2,1 I.f <br /> Owner DBA d}}S(MpSpI}U�. <br /> OwnerAddress 4025 CORONADO AVE <br /> STOCKTON. CA 952042344 <br /> Home Phone Not Specified <br /> Work/Business Phone <br /> Mailing Address -PQ- g6---, <br /> 5•T9S K�9N-6fF-952 @8 <br /> Care of <br /> FACILITY FILE INFORMATION Site Mitigation Facility <br /> Facility ID/CERS ID FA0003806 10181437 <br /> Facility Name 4. — <br /> Location 4025 CORONADO AVE <br /> STOCKTON, CA 95204 <br /> Phone 209.,466-1477-x, ® John Neil Stevens <br /> Vice President <br /> Mailing Address Real Estate Asset Manger <br /> S+E)G KTON;-CA-9§204--- <br /> Care of Credit Management Group <br /> Location Code 01 -STOCKTON MAC A0397-031 <br /> Bos District 002-MILLER, KATHERINE 1655 Grant St.3rd FloorConcord,CA 94520 <br /> APN 11530025 Tel: 925 483 9403 <br /> Fax: 925 483 9116 <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION Cell:510 206 7818 <br /> Contact Name ,I <br /> wens Fargo Bank NA. jolutstevens@wellsfargo.com <br /> Title <br /> Day Phone I <br /> Night Phone � <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0003391 �/ Vl New Account ID: <br /> Mail Invoices to ACCOUnt �1 II Ir1`�Nda's to: Owner / Facility / Account <br /> Account Name Krystal-jacks, /� r �\ VVV (circle One) <br /> Account Balance as of 5/24/2018: $1 .10 <br /> h1D <br /> / (Circle One) <br /> Transferto ANveMacNe <br /> Program/Element and Description Record ID EmplName Status New OwneR Delete <br /> 1921 -HMBP-Regular-Primary Location PR0526240✓ EE0009817-ROBERT LOPEZ Active Y N AD <br /> 2221 -USED OIL ONLY-<5 TONSNR PR0538460 EE0001421 -STACY RIVERA Active Y N A D <br /> 2381 -UST FACILITY(BEFORE 1/84)-obsolete PR0231068 EE0000008-LETITIA BRIGGS Inactive Y N A D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGI PRO534381 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andror project specific,PHSIEHD hourly charges associated with this facility <br /> or activity will be billed to the parry identified as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes andror Standards and State andor <br /> Federal Laws. - <br /> APPLICANT'S SIGNATURE: Date / / <br /> Program Records to be TRANSFERED: `$25.00= Amount Paid Date / / <br /> Water System!o,5e TRANSFERED: Amount Paid Date <br /> Payment Typ Check Number Received by <br /> EHD Staff: Date_,S-- / ! ! r_ Account out: Date / / <br /> COMMENTS: <br /> Invoice#: <br /> �l.Ce � �-u Gar►�Gu� �'�r G{l�n.k� . <br />