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Date run . 2/28/2017 11:32:35AI SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report a5021 1 <br />Run by DONNA Pagel <br />Facility Information as of 2/28/2017 <br />Record Selection Criteria: Facility ID FA0015873 <br />OWNER FILE INFORMATION Number of facilities for this owner <br />Owner ID <br />OW0012794 <br />Owner Name <br />DGR.X+FKJ— <br />Owner DBA <br />Owner Address <br />124 N E ST <br />STOCKTON, CA 95205 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />peg -X7_7994 <br />Mailing Address <br />P6007 -b8 <br />STOCKTON, CA 95205-0847 <br />Care of <br />FACILITY FILE INFORMATION / <br />Facility ID / CERS ID FA0015873 185039 <br />Facility Name NUMERI TECH IN <br />Location 124 N E ST <br />STOCKTON, A 95205 <br />Phone 209-227-7 4 x <br />Mailing Address PO BO 847 <br />STO ON. CA 95205-0847 <br />Care of DodKing <br />Location Code 7 <br />BOS District 001 - VILLAPUDUA, CARLOS <br />APN 15318002 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name DON KING <br />Title <br />Day Phone 209-227-7394 x0 <br />Night Phone X0 <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0027629 <br />Mail Invoices to Account <br />Account Name NUMERI TECH INC <br />Account Balance as of 2/28/2017: $2,152.00 <br />Program/Element and Description <br />Make changes/corrections in RED ink. -7 All <br />INFORMATION CHANGE (date) / I <br />OWNERSHIP CHANGE (date) <br />SSN /Fed Tax ID <br />New Owner ID : <br />fid: 4 <br />V r'i� � A . <br />y- 1 <br />e 4 S- O ( <br />Alt Phone <br />Fax <br />EMail : <br />New Account ID: : <br />Mail Invoices to: Owner / Facility / Account <br />(Circle One) <br />Record ID Employee ID and Name <br />(Circle One) <br />Transfer to Active/InacNe <br />Status New Diener? Delete <br />1921 - HMBP-Regular-Primary Location PRO523494 EE0009817 - ROBERT LOPEZ Active Y N A I D <br />2220 - SM HW GEN <5 TONSNR PRO538497 EE0000023 - PAULINE MANGRAI Active Y N A I D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARG PRO531563 Inactive Y N A I D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, Ne undersigned owner, operator or agent of same, acknowledge that all site, andor proieer spocigq PH&EHD hourly charges associated with this facility <br />or activity will be billed to the party identified as this, OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and State ander <br />Federal Laws. <br />APPLICANT'S SIGNATURE: <br />Program Records to be TRANSFERED: <br />Water System to be TRANSFERED: <br />Payment Type Check Number <br />EHD Staff: <br />COMMENTS: <br />` $25.00 = <br />Date <br />Date <br />Amount Paid Date _ <br />_ Amount Paid Date <br />Received by <br />Account out: <br />Invoice #: <br />�a�� r�-�rn �nd�ca-des no �orc��r �h ��-s�ncss�-y��c.�e odvise <br />