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Data run 3/21/2016 3:34:07PR SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> Run by (brown Report 785021 <br /> Facility Information as of 3/21/2016 Pagel <br /> Racord Selection Criteria: Facility ID FA0019674 <br /> Make changeslcorrections in RED ink <br /> INFORMATION CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 OWNERSHIP CHANGE(date) <br /> New/Fed Tax ID <br /> Owner ID <br /> OW0016131 New Owner ID <br /> Owner Name STOCKTON PORT DISTRIBUTION ppl--{ <br /> Owner DBA STOCKTON PORT DISTRIBUTION <br /> Owner Address 2201 W WASHINGTON ST <br /> STOCKTON, CA 95203 <br /> Home Phone 209-946-0246 <br /> Work/Business Phone Not Specified <br /> Mailing Address PO BOX 2089 <br /> STOCKTON, CA 95201 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0019674 <br /> Facility Name STOCKTON PORT DISTRIBUTION L-L"n ici rt7�i—• <br /> Location 120 HOOPER ST <br /> STOCKTON, CA 95203 <br /> Phone 209-946-0246 <br /> Mailing Address PO BOX 2089 <br /> STOCKTON, CA 95201 <br /> Care of <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOB District 003-BESTOLARIDES, STEVE Fax <br /> APN 16203007 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 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name STOCKTON PORT•BISTRIBUTiDN (CirdeOne) <br /> Account Balance as of 3/21/2016: $274.00 <br /> (Circle One) <br /> Transfer to ActiveaInacive <br /> ProgramlElement and Description Record ID Employee ID and Name Statue New Owner? Delete <br /> 1921 -HMBP-Reqular-Primary Location PR0529837 EE0009817-ROBERT LOPEZ Inactive Y N A I D <br /> 2220-SM HW GEN<5 TONSNR PRO540847 EE0001421-STACY RIVERA Active Y N A I D <br /> 2831 -AST FAC >/=1,320-<10 K GAL CUMULATIVE PRO540846 EE0001421 -STACY RIVERA Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: L the undersigned owner,operator or agent or 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 identAed as the OWNER on this form. I also certify that all operations will he performed in accordance with all applicable Ordinance Codes andor Standards and State andor <br /> Federal Laws, <br /> APPLICANTS SIGNATURE: Date I / <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Cfieck Number Received by <br /> EHD Staff: Date / / Account out: Date <br /> COMMENTS: <br /> rpFil <br /> ce <br /> oetinr� Sfo fin 9rlt°IDisty <br /> oaLl lr k ���� <br />