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Daterun 9/26/2014 11:47:02AI SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 9/26/2014 <br /> Record Selection Criteria: Facility ID FA0020926 <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 OW0017218 New Owner ID <br /> Owner Name ABC WALLACE FUNERAL SERVICES <br /> Owner DBA <br /> Owner Address 445 N AMERICAN ST <br /> STOCKTON, CA 95202 <br /> Home Phone 209-464-5329 <br /> Work/Business Phone Not Specified <br /> Mailing Address 445 N AMERICAN ST <br /> STOCKTON, CA 95202 <br /> Care of FRY, GLENN <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0020926 <br /> Facility Name ABC WALLACE FUNERAL SERVICES <br /> Location 445 N AMERICAN ST <br /> STOCKTON, CA 95202 <br /> Phone 209-464-5329 <br /> Mailing Address 445 N AMERICAN ST �►'Ia.G 1y1G �SS7 Der �Q .m• _ <br /> STOCKTON, CA 95202 <br /> Care of FRY, GLENN <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 001 -VILLAPUDUA Fax <br /> APN 13923014 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name FLENN FRY <br /> Title <br /> Day Phone 209-464-5329 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0037620 New Account ID: <br /> Mail invoices to Facility Mail Invoices to: Owner 1 Facility / Account <br /> Account Name ABC WALLACE FUNERAL SERVICES (Circle One) <br /> Account Balance as of 9/26/2014: $0.00 <br /> (Circle One) <br /> Transfer to Activellnactve <br /> ProgramlElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 4557-MED WASTE LIMITED HAULER PRO536439 EE0003973-ROBERT MCCLELLON Active Y N A O D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,anr➢or 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. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes andlor Standards and State andlor <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date / ! <br /> Program Records to be TRANSFERED: "$25.00= Amount Paid Date / 1 <br /> Water System to be TRANSFERED: Amount Paid Date 1 1 <br /> Payment Type Check Number Rereeived by <br /> REHS: eSl1.._ r kk" Date 6 1 *t... / Account out: Date _/9! 14 <br /> COMMENTS- <br />