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Date run 11/3/2017 10:49:52AI SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 11/3/2017 <br /> Record Selection Criteria: Facility ID FA0019674 <br /> Make changesfcorrections 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 OW0016131 New Owner ID <br /> Owner Name Port of Stockton <br /> Owner DBA STOCKTON PORT DISTRICT <br /> OwnerAddress 2201 W WASHINGTON ST <br /> STOCKTON, CA 95203 <br /> Home Phone 209-946-0246 <br /> Work/Business Phone 209-946-0246 <br /> Mailing Address PO Box 2089 <br /> Stockton, CA 95201 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0019674 10725229 <br /> Facility Name STOCKTON PORT DIST(STOCKTON, CA) <br /> Location 120 Hooper Dr <br /> Stockton, CA 95203 <br /> Phone 209-946-0246 x <br /> Mailing Address 2201 W Washington St <br /> Stockton, CA 95203 <br /> Care of Stockton Port District <br /> Location Code 01 - STOCKTON Alt Phone <br /> BOB District 003- BESTOLARIDES, STEVE Fax <br /> APN 162-030-01 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 AR0035036 f�/ °� NewAccount ID: <br /> Mail Invoices to Account �/< Mail Invoices to: Owner / Facility / Account <br /> Account Name Port of Stoc n Y— (Circle one) <br /> Account Balance as of 11/3/2017: $9 .00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PRO529837 EE0009817-ROBERT LOPEZ Active Y N AD <br /> 2220-SM HW GEN<5 TONS/YR PR0540847 EE0001421 -STACY RIVERA Active Y N A I D <br /> 2831 -AST FAC >/= 1,320-<10 K GAL CUMULATIVE PR0540846 EE0001421 -STACY RIVERA Active Y N A D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andor project specific,PHS/EHD hourly charges associated with this facility <br /> or activity will be billed to the party identied as the OWNER an this form. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes and/or Standards and Slate 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 ��--y Received bre, <br /> EHD Sta Date & L i� Account out: (�T Date <br /> COMMENTS: <br />