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Date run 3/11/2016 12:09:15PI SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by (brown Pagel <br /> Facility Information as of 3/11/2016 <br /> Record Selection Criteria: Facility ID FA0019674 <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/Fed Tax ID <br /> Owner ID OW0016131 New Owner ID <br /> Owner Name DELTA REMOVAL & DEMOLITION <br /> Owner DBA DELTA REMOVAL & DEMOLITION <br /> Owner Address 4011 E MORADA LN 140 <br /> STOCKTON, CA 95212 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address 120 HOOPER ST <br /> STOCKTON, CA 95203 <br /> Care of BRIAN CARPENTER <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0019674 <br /> Facility Name DELTA REMOVAL & DEMOLITION <br /> Location 120 HOOPER ST <br /> STOCKTON, CA 95203 <br /> Phone <br /> c <br /> Mailing Address 120 HOOPER ST <br /> STOCKTON, CA 95203 <br /> Care of <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 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 Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name DELTA REMOVAL & DEMOLITION (Circle One) <br /> Account Balance as of 3/11/2016: $0.00 <br /> (Circle One) <br /> Program/Element and Description Record ID Employee ID and NameTransfer to Active/Inactve <br /> Status New Owner? Delete <br /> 1921 -HMBP-Reqular-Primary Location PR0529837 EE0009817-ROBERT LOPEZ InactivE Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same.acknowledge that all site,and/or project specific,PHSIEHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable ordinance Codes and/or Standards and State and/or <br /> Federal Laws. <br /> APPLICANT'S 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: Date / / Account out: Date <br /> COMMENTS: <br /> Invoice#: <br />