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Date run 11/3/2017 10:42:03AP SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report 95021 <br /> Run by Pagel <br /> Facility Information as of 11/3/2017 <br /> Record Selection Criteria: Facility ID FA0024018 <br /> Make changeslcorrections 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 OW0022488 New Owner ID <br /> Owner Name Port of Stockton <br /> Owner DBA <br /> OwnerAddress 2201 W WASHINGTON ST <br /> STOCKTON, CA 95203 <br /> Home Phone Not Specified <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 FA0024018 10725232 <br /> Facility Name STOCKTON PORT DIST(STOCKTON, CA) <br /> Location 804 Humphreys 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 Alt Phone <br /> BOS District 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 AR0044577 NewAccount ID: <br /> Mail Invoices to Account 0444 Mail Invoices to: Owner / Facility / Account <br /> Account Name Jason Cas an (Circle One) <br /> Account Balance as of 11/3/2017: 36.00 <br /> (Circle One) <br /> Transfer to Adivellnaclve <br /> Program/Element and Description Record 10 Employee ID and Name status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PRO541877 EE0009817-ROBERT LOPEZ Active Y N AD <br /> 2220-SM HW GEN<5 TONS/YR PRO541876 EE0001421 -STACY RIVERA Active 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 specific,PHSIEHD hourly charges associated with this facility <br /> or activity will be billed to the party idenlied as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinance codes andor Standards and State sndor <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 /> Pme Type heck Number Received by <br /> ayES - Date /y�/ Account out: Date <br /> COMMENTS: <br /> Invoice t1: <br />