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Date mn 4/10/2015 10:24:08AI SAN JCWIN COUNTY ENVIRONMENTAL HEAD DEPARTMENT Report 45021 <br /> Pagel <br /> Run by <br /> Facility Information as of 4/10/2015 <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 lD/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 <br /> Care of Delta Blood Bank <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 /> New Account ID: <br /> AccountlD AR0041926 : <br /> Mail Invoices to: Owner / Facility / Account <br /> Mail Invoices to Account <br /> (Circle One) <br /> Account Name Alfonso Figueroa <br /> Account Balance as of 4/10/2015: $0.00 (Clicle one) <br /> Transferto Activellnaiave <br /> Program/Element and Description <br /> Record ID Employee ID and Name Status New Owner? Delete <br /> 2220-SM HW GEN<5 TONS/YR PR0539982 EE0002646-THUY TRAN Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,anclor project specific.PHSfEHD hourly charges associated with thisfacilily <br /> or activity will be billed to the party identified as the OWNER on this farm. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes and/or Standards and State and/or <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 Type Check Number Received b <br /> REHS: ��? Date�._/� O / 1 Account out: Date <br /> COMMENTS: <br /> CQwr--D NEW Fat�1`'l T- QY+- C A—P im V 1 A <br /> Ik �L <br />