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Date ran 6/5/2017 5:01:46PM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Reportnso2l <br /> Run by Pagel <br /> Facility Information as of 6/5/2017 <br /> Record selection Craters: Facility ID FA0023772 <br /> Make changealcolrections 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 OW0022108 New Owner ID <br /> Owner Name Golden State Bridge Inc. <br /> Owner DSA <br /> Owner Address 3701 MALLARD DR <br /> BENICIA, CA 94510 <br /> Home Phone 925-372-8000 <br /> Work/Business Phone 925-372-8000 <br /> Mailing Address 3701 Mallard Drive <br /> Benicia,CA 94510 <br /> Care of LANZA, MARIA <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0023772 10718107 <br /> Facility Name Golden State Bridge Stockton Yard <br /> Location 321 Lipes Dr <br /> Stockton, CA 95205 <br /> Phone 925-372-8000 x <br /> Mailing Address 3701 Mallard Drive <br /> Benicia, CA 94510 <br /> Care of Golden State Bridge Inc.Stockton Yard <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name LANZA, MARIA <br /> Title <br /> Day Phone 925-372-8000 <br /> Night Phone xThomas <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0044002 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name Stefany Russell (Circle One) <br /> Account Balance as of 6/5/2017: $0.00 <br /> (Close One) <br /> Program/Element and Description RecoN ID Em to ID and Name 00'dinanw <br /> Tianalerto ActfveMacNe <br /> Employee ew Owner? Delete <br /> 1921-HMBP-Regular-Primary Location PRO541466 EE0009817-ROBERT I ElY N A D <br /> 2239-REMOTE WASTE CONSOLIDATION SITE PRO541484 EE9999996-THREE VACANT3Y N A D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,ackrwwledge that all site,andtor projectsesassociatedwith Nisfacility <br /> oractlelly will be billed to Ne party Identified as me OWNER on Nis forth I also certify Install oper.bons will be performed in accordance wird all appl User Standards and State andPor <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: lr> Date <br /> COMMENTS: <br /> CSV l VInvoice <br /> � J / ` //J #: <br /> oc�' � �. <br />