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Date run 2/27/2015 9:52:21Ah SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report 05021 <br /> Run by Pagel <br /> Facility Information as of 2/27/2015 <br /> Record Selection Criteria: Facility ID FA0013523 <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: 5 SSN/Fed Tax ID <br /> Owner ID OW0010634 New Owner ID <br /> Owner Name S J CO PUBLIC WORKS/UMD <br /> Owner DBA <br /> Owner Address 1702 E SCOTTS AVE <br /> STOCKTON, CA 95205 <br /> Home Phone 209-468-3000 <br /> Work/Business Phone 209-468-3090 <br /> Mailing Address 1702 E SCOTTS AVE <br /> STOCKTON, CA 95205 <br /> Care of SJ CO PUBLIC WORKS DEPT <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0013523 10184389 <br /> Facility Name PUBLIC WORKS/ UTILITY FAIROAKS#1 <br /> Location 8701 FELIZ WAY <br /> TRACY, CA 95376 <br /> Phone 209-468-3090 x <br /> Mailing Address 1702 E SCOTTS AVE <br /> STOCKTON, CA 95205 <br /> Care of RALL, RON <br /> Location Code Alt Phone <br /> BOIS District Fax <br /> APN 24811051 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0022627 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name PUBLIC WORKS/UTILITY FAIROAKS#1 (clrea,One) <br /> Account Balance as of 2/27/2015: $0.00 <br /> (Circle One) <br /> Transfer!. Active/Inadve <br /> Progra"Element and Description Record ID Employee ID and Name Status New OwneO Delete <br /> 1926-HMBP-Unstaffed Network Location PR0517615 EE0009817-ROBERT LOPEZ Active Y N AI D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PR0517614 EE0o00000-HAZ MAT SJC OES Inactivt Y N A D <br /> 2840-AST EXEMPT FAC < 1,320 GAL PR0529090 EE0000753-WILLY NG Inactivt Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andor project specific,PHS/EHD hourly Merges associated with this fadlity <br /> or activity will be billed to the Party identified as the OWNER on this farml also certify that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and State andor <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 /> Paymen ype Check Number Received 1py /{ <br /> REHS: Date / / Account out: Date / I <br /> COMMENTS <br /> As <br /> fff <br /> I U3Yn � Xl c��mm`tSS i <br />