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Date run 11/10/2020 10:33:13/ SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 11/10/2020 <br /> Record Selection Criteria: Facility ID FA0002060 <br /> Make changesicorrections 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 OW0001611 New Owner ID <br /> Owner Name THOMPSON, CARL JR <br /> Owner DBA INN AT PALM CROSSINGS <br /> OwnerAddress 1919 GRAND CANAL B5 <br /> STOCKTON, CA 95207 <br /> Work/Business Phone 209-477-5576 <br /> Alternative Phone 209-951-9448 <br /> Mailing Address 1919 GRAND CANAL B5 <br /> STOCKTON, CA 95207 <br /> Care of THOMPSON, CARL JR <br /> FACILITY FILE INFORMATION APN 11619003 <br /> Facility ID/CERS ID FA0002060 <br /> Facility Name INN AT PALM CROSSINGS <br /> Location 2717 W MARCH LN <br /> STOCKTON, CA 95207 <br /> Phone 209-477-5576 <br /> Mailing Address 1919 GRAND CANAL B5 <br /> STOCKTON, CA 95207 <br /> Care of THOMPSON, CARL JR <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name THOMPSON, CARL JR <br /> Title <br /> Day Phone 209-477-5576 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0002068 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name INN AT PALM CROSSINGS (Circle One) <br /> Email invoice to(up to 2 emails) <br /> '�7 <br /> Email permit to(up to 2 emails) �\1I I�o#-�/ lit <br /> Account Balance as of 11/10/2020: $587.00 C41 I� l0 SDI' <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1612-FOOD EST<500 SQ FT W/O SEATING PR0526363 EE0006213-VIDAL PEDRAZA Active Y N A I D <br /> 2409-HOTEL/MOTEL>90 PR0240115 EE0002089-OMRAN SOOD Active Y N A O D <br /> 3611 -PUBLIC POOL/SPA-PRIMARY PR0360130 EE0006213-VIDAL PEDRAZA Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific,PHS/EHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes and/or Standards and State andlor <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 <br /> EHD Staff: Date / / 710 ZvAccount out: Date 77 / /2c-> <br /> COMMENTS: e / <br /> e- !'u -ci4 Invoice#: <br /> ed fi rr c <br /> 231 20 , E 0 <br /> G+ V-19- 1q . <br />