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Da1enun 10114/2015 9:50:02A SAN JO�JIN COUNTY ENVIRONMENTAL HEAT I DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 10/14/2015 <br /> Record Selection Criteria: Facility 10 FA0017042 <br /> Make changesicorrections In RED Ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSNI Fed Tax ID <br /> Owner ID OW0013883 New Owner ID <br /> Owner Name ROD DEMENT <br /> Owner DBA ROD DEMENT <br /> Owner Address 3761 BROOK VALLEY CIR <br /> STOCKTON, CA 95219 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address 3761 BROOK VALLEY CIR <br /> STOCKTON. CA 95219 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0017042 10185799 <br /> Facility Name ROD DEMENT <br /> Location 1725 S HOLT RD <br /> STOCKTON, CA 95206 <br /> Phone 559-469-5146 x0 <br /> Mailing Address 3761 BROOK VALLEY CIR <br /> STOCKTON, CA 95219 <br /> Care of <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 13106005 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 AR0029924 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name ROD DEMENT (Circle one) <br /> Account Balance as of 10/14/2015: $505.00 <br /> (Circle One) <br /> Transfer to A0ve/InaMe <br /> PmpramlElement and Description Reoard ID Employee ID and Name Status <br /> New Omer' Delete <br /> 1958-HM-Farm Operations PRO525227 EE0009817-ROBERT LOPEZ Active Y N A ® D <br /> 2220-SM HW GEN<5 TONSNR PR0530933 EE0001421 -STACY RIVERA Active Y N A D <br /> 2830-AST FAC -SPCC EXEMPT PR0530932 EE0001 421 -STACY RIVERA Active Y N A D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO532245 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andor project speck,PHSIEHO hourly charges associated with this facitlty, <br /> or activity will be billed to the party,identified as the OWNER on this form. I also mrtify that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and State andor <br /> Federal Laws. p <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 by <br /> EHD Staff: M Date 7 o I 7y /_Z_C_ Account out: Date./0 <br /> COMMENTS: <br /> Invoice#: <br />