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Date run 1113/2017 2:02:04PK SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 1113/2017 <br /> Record Selection Criteria: Facility ID FA0023829 <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 1 Fed Tax ID <br /> Owner ID OW0022210 New Owner ID <br /> Owner Name DEPT. OF V.A. <br /> Owner DBA <br /> Owner Address <br /> Home Phone Not Specified <br /> Work/Business Phone 202-273-4960 <br /> Mailing Address $10 VERMONT AVE.,. NW <br /> WASHINGTON, DC 20420 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID(CERS ID FA0023829 10723045 <br /> Facility Name STOCKTON V.A. CBOC <br /> Location 7777 S Freedom Rd <br /> French Camp, CA 95231 <br /> Phone 650-493--5000 X <br /> Mailing Address 7777 S Freedom Rd <br /> French Camp, CA 95231 <br /> Care of PALO ALTO V.A. HEALTH CARE SYSTEM <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN FMail <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0044145 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility ! Account <br /> Account Name ROY RAMIREZ (Circle One) <br /> Account Balance as of 111312017: $0.00 <br /> (Circle One) <br /> Transfer to Activellnactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2220-SM HW GEN <5 Toll PRO541561 EE0000023-PAULINE MANGRAI Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT. I,the undersigned owner,operator or agent of same,acknowledge that all site,andlor project specific..PH&EHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this form. 1 also certify that all operations will be performed in accordance with all applicable Ordinance Codes andlor Standards and State and+or <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE Date J ! <br /> Program Records to be TRANSFERED: `$25.00 Amount Paid Date I 1 <br /> Water System to be TRANSFFRED: Amount Paid Date ! / <br /> Payment Type Check Number Received b <br /> EHD Staff. G 6 IA � Date�1�1�Z Account out: J Date ! 0-7 <br /> COMMENTS. V <br /> InV0ice#: <br /> crmf.ed buJrd on Ctrs S10n-"j <br />