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Date run 02/2017 4:54:52PR SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Run Uy Facility Information as of 6/12/2017 Report #5021 Pagel I Record Selection Criteria: Facility ID FA0009932 A I OWNER FILE INFORMATION Number of facilities for this owner Owner ID OW0016111 Owner Name BEBf;Zia Owner DBA Active/Inactve Owner Address New Owner? Home Phone Not Specified Work/Business Phone 294 2 54noG-- Mailing Address I D Care of Y N FACILITY FILE INFORMATION Facility ID / CERS ID FA0009932 10183041 Facility Name Location 1001 W CHARTER WAY STOCKTON, CA 95206 Phone.. Mailing Address p0-ga� Care of CA -962-3 -- Location Code 01 - STOCKTON BOS District 001 - VILLAPUDUA, CARLOS APN 16323043 EMERGENCY NOTIFICATION CONTACT INFORMATION O Contact Name J Title Day Phone Night Phone ACCOUNTS RECEIVABLE FILE INFORMATION Account ID AR0016932 Mail Invoices to Owner Account Name —N ING Account Balance as of 6/12/20 : $1,045.50 Make changes/corrections in RED ink. INFORMATION CHANGE (date) OWNERSHIP CHANGE (date) SSN / Fed Tax ID New Owner ID : .Z 0 c Ji o '�n c .r �✓ c 6 O Alt Phone Fax 17 © O s' e . - 4=2.4 C' A EMail : + 4Q v ,JJ V0 New Account I D: Mail Invoices to: Owner / Facility / Account (Circle One) Program/Element and Description Record ID Employee ID and Name 1921 - HMBP-Reqular-Primary Location PR0519968 EE0009817 - ROBERT LOPEZ 2224 - HAZ MAT BUSINESS PLAN AUTHORIZATION PR0512220 EE0000000 - HAZ MAT SJC OES 2399 - UNIFIED PROGRAM FAC STATE SURCHARGE FI PR0509932 EE0000000 - HAZ MAT SJC OES ERSC - ELECTRONIC REPORTING STATE SURCHARGI PRO532846 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 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 and/or Federal Laws. APPLICANT'S SIGNATURE: Program Records to be TRANSFERED: * $25.00 = Water System to TRANSFERED: Payment Type Check Number EHD Staff: Date COMMENTS Date / !. Amount Paid Date Amount Paid Date Received bm Account out: Date 7 Invoice #: .2q�f�0 7 (Circle One) Transfer to Active/Inactve Status New Owner? Delete Ina Y N A I D tIvE Y N I D Inactive Y N I D Inactive Y N A I D 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 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 and/or Federal Laws. APPLICANT'S SIGNATURE: Program Records to be TRANSFERED: * $25.00 = Water System to TRANSFERED: Payment Type Check Number EHD Staff: Date COMMENTS Date / !. Amount Paid Date Amount Paid Date Received bm Account out: Date 7 Invoice #: .2q�f�0 7