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Daterun 7/8/2015 9:13:37AM SAN JOAGP COUNTY ENVIRONMENTAL HEALWEPARTMENT Report#5021 <br /> Run by ' Pagel <br /> Facility Information as of 7/8/2015 <br /> Record Selection Criteria: Facility ID FA0022259 <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 OW0018543 New Owner ID <br /> Owner Name PORT OF STOCKTON, ROUGH & READY <br /> Owner DBA <br /> Owner Address 2201 W WASHINGTON ST <br /> STOCKTON, CA 95201 <br /> Home Phone 209-946-0246 <br /> Work/Business Phone Not Specified <br /> Mailing Address 2201 W WASHINGTON ST <br /> STOCKTON, CA 95201 <br /> Care of ESCOBAR, STEVE <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0022259 <br /> Facility Name PORT OF STOCKTON, ROUGH & READY <br /> Location 718 MCCLOY AVE <br /> STOCKTON, CA 95203 <br /> Phone <br /> Mailing Address 718 MCCLOY AVE <br /> STOCKTON. CA 95203 <br /> Care of <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 003 - BESTOLARIDES, STEVE Fax <br /> APN 16203007 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION 5cf <br /> Account ID AR0040627 ^ � New Account ID: <br /> Mail Invoices to Account /t Mail Invoices to: Owner / Facility / Account <br /> Account Name ENVIRONMENTAL RISK SERVICES (Circle One) <br /> Account Balance as of 7/8/2015: $5.00 <br /> (Circle One) <br /> Transfer to Active/InaMe <br /> PrograMElement and Description Record ID Employee ID and Name Status New Owner' Delete <br /> 2950-ENVIRON ASSESS PRO638761 EE0001699-JOHNNY YOAKUM Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,ander project specific.PHSIEHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this form. l also certify that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and Statesndor <br /> Federal La.. <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 b <br /> EHD Staff: Date / / Account out: Date /Z//5 <br /> COMMENTS: <br /> Invoice#: <br />