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Date run 12/11/2017 11:49:54,4 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 12/11/2017 <br /> Record selection Criteria: Facility ID FA0003019 <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: 10 SSN/Fed Tax ID <br /> Owner ID OW0007847 Case Number: H05625 New Owner ID <br /> Owner Name CITY OF STOCKTON - PARKS& REC <br /> Owner DBA <br /> Owner Address 6 E LINDSAY ST <br /> STOCKTON, CA 95202 <br /> Home Phone Not Specified <br /> WorkBusiness Phone 209-937-8298 <br /> Mailing Address 605 N EI Dorado Street <br /> STOCKTON, CA 95202-1997 <br /> Care of CRUZ,ADOLFO <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0003019 10671355 <br /> Facility Name BROOKING PARK POOL <br /> Location 4500 NUGGET AVE <br /> STOCKTON, CA 95207 <br /> Phone 209-937-8341 x <br /> Mailing Address 1465 S Lincoln St <br /> Stockton, CA 95206 <br /> Care of City of Stockton <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 002- MILLER, KATHERINE Fax <br /> APN 10232037 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name WEBERSTOWN HOA POOL <br /> Title <br /> Day Phone 209-474-7438 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0003401 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name Brad Mettler (Circle One) <br /> Account Balance as of 12/11 2017: $0.00 <br /> K��d ZO I � � N Circle One) <br /> Transfer to ActivrJlnactve <br /> Program/Element and Desorption Record ID Emplo a ID and Name Status New Owner? Delete <br /> 1620-RETAIL MKT 26-300 SO FT(INCIDENTAL FOODS; PR0528702 EE0003361 -MARIBEL FLOHRSCHUTZ Inactive Y N A �I D <br /> 1921 -HMBP-Regular-Primary Location PRO541060 EE0008709-JAMIE LIMA Active Y N A D <br /> 3616-PUBLIC POOLISPA-EXEMPT PR0360492 EE0003361 -MARIBEL FLOHRSCHUTZ Active Y N A D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledae that all site,andfor protest specdic,PHSfEHD hourly charges associatetl with this facility <br /> or activity will be billed to the parry identified as the OWNER on this form. I also sandy that all operations will be performed in accordance with all applicable Ordinance Codes andfor Standards and State andlor <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Check Number Received by <br /> EHD Staff: .`WYE— Date Account out: Date / l s IL <br /> COMMENTS: invoice#: <br /> Bus i rlRZ3 I\a$ S ao a +it,3 4 <br /> 'i1��1F�4A�Ip.✓` rV�h�vt,c�I (.✓"-o. d�. t�� L�Y <br /> '—1 i—� doe-s, o,.e4 gr jT c <br />