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Date run 5/29/2015 11:49:52AI SAN JOIN COUNTY ENVIRONMENTAL HEA DEPARTMENT <br /> Run by Report M5021 <br /> Facility Information as of 5/29) Pagel <br /> Record Selection Criteria: Facility ID FA0021094 <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 <br /> SSN/Fed Tax ID <br /> Owner ID OW0017365 New Owner ID <br /> Owner Name ZAMORANO, MARIA& CHRISTIAN <br /> Owner DBA FORMER SIEBOLD CONSTRUCTION <br /> Owner Address 2114 AZTEC AVE <br /> STOCKTON, CA .95266 r1 SyQ� <br /> Home Phone 209-470-3905 <br /> Work/Business Phone Not Specified <br /> Mailing Address 32.6 tQ«�1- <br /> STOCKTON, CA 9320& q s 217L <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0021094 <br /> Facility Name FORMER SIEBOLD CONSTRUCTION <br /> Location 824 S AMERICAN ST <br /> STOCKTON, CA 95206 <br /> Phone 209-470-3905 <br /> Mailing Address 3264 j�r��E-T-R&_, ) `Lq A_ /ri `t <br /> STOCKTON, CA-95205- <br /> Care of MARIA&CHRISTIAN ZAMORANO <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 001 -VILLAPUDUA, CARLOS Fax <br /> APN 14729211 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name MARIA& CHRISTIAN ZAMORANO <br /> Title <br /> Day Phone 209-470-3905 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0037989 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name `^r ^'z_,�„� _P&K t\ ��C _ <br /> (Circle One) <br /> "I lJ <br /> Account Balance as of 5/29/2015 $-1,312.50 <br /> (Circle One) <br /> Program/Element antl4escdption Record ID Employee ID and Name Transfer to Active0nacive <br /> I'ZWQC8 GCcrf6, Vp Status New O <br /> � wner? Delete <br /> PR0536718 EE0001699-JOHNNY YOAKUM Active Y N I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,anclor project specific,PHS•EHD hourly charges associatetl with this facility <br /> or activity,will be billed to the parry identified 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 andfor <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 Receiv by <br /> EHD Staff: Date `—/�/ f Account out: <br /> COMMENTS: <br /> Invoice#: <br />