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Date run 3/29/2017 4:14:44PN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 3/29/2017 <br />Record Selection Criteria: Facility ID FA0016197 <br />OWNER FILE INFORMATION Number of facilities for this owner <br />Owner ID <br />OW0013093 <br />Owner Name <br />VIC ACQUISTAPACE <br />Owner DBA <br />FALCO CONSTRUCTION <br />OwnerAddress <br />3808 E FARMINGTON RD <br />Mailing Address <br />STOCKTON, CA 95215 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />209-479-3560 <br />Mailing Address <br />3808 E FARMINGTON RD <br />BOS District <br />STOCKTON, CA 95215 <br />Care of <br />17307001 <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID FA0016197 10185101 <br />Facility Name <br />FALCO CONSTRUCTION <br />Location <br />3808 E FARMINGTON RD <br />STOCKTON, CA 95215 <br />Phone <br />209-463-2806 x0 <br />Mailing Address <br />3808 E FARMINGTON RD <br />STOCKTON, CA 95215 <br />Care of <br />Falco Construction <br />Location Code <br />BOS District <br />001 - VILLAPUDUA, CARLOS <br />APN <br />17307001 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Make changes/corrections 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' il: <br />Account ID AR0028320 <br />Mail Invoices to Owner Mail Invoices to: <br />Account Name VIC ACQUISTAPACE <br />Account Balance as of 3/29/2017: $0.00 <br />New Account ID: : <br />Owner / Facility / Account <br />(Circle One) <br />(Circle One) <br />Transfer to Active/Inactve <br />Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br />1921 - HMBP-Regular-Primary Location PR0524106 EE0008709 - JAMIE LIMA Active Y N A I D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARGE PR0534521 Inactive Y N A 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 andror <br />Federal Laws. <br />APPLICANT'S SIGNATURE: <br />Date / / <br />Program Records to be TRANSFERED: * $25.00 = Amount Paid Date <br />Water System to be TRANSFERED: Amount Paid Date / / <br />Payment Ty p Check Number Received b <br />EHD Staff: �� �_ Date / /177 Account out: Date /71/17 <br />COMMENTS: <br />Invoice #: <br />Oe <br />