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Datemn 5/8/2017 11:36:68AM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> Run by Report#5021 <br /> Facility Information as of 5/8/2017 Pagel <br /> Record Selection Criteria: Facility ID FA0024018 <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 OW0022488 New Owner ID <br /> Owner Name Port of Stockton <br /> Owner DBA <br /> Owner Address <br /> Home Phone Not Specified <br /> Work/Business Phone 209-946-0246 <br /> Mailing Address PO BOX2089 <br /> Stockton, CA 95201 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/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 Eli <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 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name Jason Cashman (Circle One) <br /> Account Balance as of 5/8/2017: $0.00 <br /> (Circle One) <br /> Transfer to Acgve/Inadve <br /> Progra"Elemem and Description Record ID Employee ID and Name Status New Owne? Delete <br /> 1921 -HMBP-Regular-Primary Location PR0541877 EE0009817-ROBERT LOPEZ Active Y N A I D <br /> 2220-SM HW GEN<5 TONSNR 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,andlor project specific,PHSrEHD hourly charges associated with thlsfacilily <br /> or activity will be billed to the party identified as me OWNER on this form I also certify that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and Stale andbr <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 1 'T Check Number Received by <br /> EHD Staff: Date_�/�/ Account out: Date-- <br /> COMMENTS: <br /> ate_COMMENTS: �l <br /> G t\� 00 Invoice#: <br /> ck✓a Sti b M f'rAi- , f3 t Cry .�A <br />