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Date run 2/18/2016 10:42:50AI SAN JCWIN COUNTY ENVIRONMENTAL HEAO DEPARTMENT Report#5021 <br /> Pagel <br /> Run by <br /> Facility Information as of 2/18/2016 <br /> Record Selection Criteria: Facility ID FA0022856 <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 OW0020818 New Owner ID <br /> Owner Name Delta Blood Bank LLC <br /> Owner DBA <br /> Owner Address <br /> Home Phone Not Specified <br /> Work/Business Phone 209-943-3830 <br /> Mailing Address P.O. BOX 800 <br /> Stockton, CA 95201 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0022856 10617133 <br /> Facility Name Delta Blood Bank <br /> Location 2303 N CORRAL HOLLOW RD <br /> Tracy, CA 95376 <br /> Phone 209-943-3830 x <br /> Mailing Address P.O. Box 800 <br /> Stockton, CA 95201 JA <br /> care of Delta Blood Bank VAI y <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 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 AR0041926 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name Alfonso Flguer (Circle One) <br /> Account Balance as of 2/18/2016: $24 . 0 (Circle One) <br /> Transfer to ActiveAnactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Omer? t <br /> 2220-SM HW GEN<5 TONS/YR PRO539982 EE0001459-VICKI MCCARTNEY Active 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,PHSrEHD hourly charges associated with thi cility <br /> or activity will be billed to the party identified as the OWNER on this torn I also certify that all operations will be performed in accordance with all applicable Ordinance Codesd'or Standards and State ancVor 4' <br /> Federal Lewis 1_4 J�� I e,91v/ <br /> APPLICANT'S SIGNATURE: Date _/_ Jb,Pvl o n <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date_/_/_` 0,041, J2\"I.-dyL <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Check Number Receive by <br /> EHD Staff: Date_/ /_ Account out: Date <br /> JJal <br /> COMMENTS: ­q-�\OOp Invoice#: <br /> '\No' s60o <br /> ��✓��, �°� row w � du 110 <br /> s <br /> DxwC� a�t9��1 <br />