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Date run 2/6/2013 10:44:42AM SAN JOSIN COUNT ENVIRONMENTAL HEA*DEPARTMENTReport#5021 <br /> Run by Pagel <br /> Facility Information as of 2/6/2013 <br /> Record Selection Criteria: Facility ID FA0001719 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0000902 New Owner ID : <br /> Owner Name STOCKTON UNIFIED SCHOOL DIST <br /> Owner DBA <br /> Owner Address 701 N MADISON ST <br /> STOCKTON, CA 95202 <br /> Home Phone 209-933-7015 <br /> Work/Business Phone 209-933-7005 <br /> Mailing Address 1944 N EL PINAL DR <br /> STOCKTON, CA 95205 <br /> Care of FOOD SERVICE- BRENDA <br /> FACILITY FILE INFORMATION Site Mitigation Facility <br /> Facility ID FA0001719 <br /> Facility Name SUSD-STAGG HIGH SCHOOL <br /> Location 1621 BROOKSIDE RD <br /> STOCKTON, CA 95207 <br /> Phone <br /> Mailing Address 1944 N EL FINAL DR <br /> STOCKTON, CA 95205 <br /> Care of FOOD SERVICE- BRENDA <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOIS District 002 - RUHSTALLER, LARRY Fax <br /> APN 11009004 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name STOCKTON UNIFIED SCHOOL D <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0001718 New Account ID: <br /> Maillnvoicesto Facility Mail Invoices to: Owner / Facility I Account <br /> Account Name SUSD-STAGG HIGH SCHOOL (Circle One) <br /> Account Balance as of 2/6/2013: $-250.00 <br /> (Circle One) <br /> Prograrr/Element and DescriptionRecortl ID Employee ID and Name Status Transferto Active/inactve <br /> New Owner? Delete <br /> 1632-EXEMPT FOOD PRO160565 EE0003361 -MARIBEL FLOHRSCHUTActive Y N A I D <br /> 2381 -UST FACILITY(BEFORE 1/84)-obsolete PRO503394 EE0000418-MICHAEL KITH Inactive Y N A I D <br /> 3616-PUBLIC POOUSPA-EXEMPT PR0360135 EE0003361 -MARIBEL FLOHRSCHUTActive 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,PHS/EHD hourly charges associated with this facility <br /> or activity will be billed to the parry identified as the OWNER on this form l also car iry that all operations will be performed in accordance with all applicable Ordinance Codas andor Standards and State andor <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 /> REHS: Date_/ / Account out: Date_/_/_ <br /> COMMENTS: <br />