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Date run 4/13/2018 2:07:43PN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report 7!5021 <br />Run by Pagel <br />Facility Information as of 4/13/2018 <br />Record Selection Criteria: Facility ID FA0020694 <br />OWNER FILE INFORMATION Number of facilities for this owner: 1 <br />Owner 1D <br />OW0017003 <br />Owner Name <br />Katherine McConvey <br />Owner DBA <br />KMM Telecommunications <br />OwnerAddress <br />4051 N HWY 121 RD 400 <br />GRAPEVINE, TX 76051 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />973-396-8297 <br />Mailing Address <br />4051 N Hwy 121 Ste 400 %X\1 <br />Care of <br />Grapevine, TX 76051 % <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID <br />FA0020694 1 0 <br />Facility Name <br />Telecommunica <br />KMM tions <br />Location <br />4212 Pock Ln <br />Stockton, CA 95206 <br />Phone <br />209-234-6841 x <br />Mailing Address <br />4051 N Hwy 121 STE 400 <br />Grapevine, TX 76051 <br />Care of <br />KMM Telecommunications <br />Location Code <br />BOS District <br />APN <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone /It <br />ACCOUNTS RECEIVABLE FILE INFORMATION I/[//\ <br />Make changesicorrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />SSN / Fed Tax ID <br />New Owner ID : <br />Alt Phone <br />Fax <br />El l <br />Account ID AR0037111 7 h' <br />Mail Invoices to Account o�� <br />Account Name Trisha Childs�� 40. <br />Account Balance as of 4/13/2018: $0.00 <br />Program/Element and Description Record ID Employee ID and Name <br />Mail Invoices to: <br />New Account ID: : <br />Owner / Facility / Account <br />(Circle One) <br />(Cine One) <br />Transfer to Activelnactve <br />Status New OwneRelete <br />1921 - HMBP-Regular-Primary Location PR0535935 EE0009817 - ROBERT LOPEZ Active Y N A D <br />2220 - SM HW GEN <5 TONS/YR PRO539395 EE0001421 - STACY RIVERA Inactive Y N A I D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARGE PR0536021 Inactive Y N A 1 D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, andor project specific, Pl1SEHD hourly charges associated with this facility <br />or atlivfly will be billed to Ne parry, identif ed as the OWNER on this form. I also caddy that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and State andior <br />Federal Laws <br />APPLICANT'S SIGNATURE: <br />Date if <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 py d <br />EHD Staff. Date /1T/ Account out: LA5 Date <br />COMMENTS: <br />Invoice #: <br />P�n�amfi'.n,�... p20 s35 93iS� �A D �b�r <br />r - <br />00 T 163 <br />I a `i^ 670 <br />