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Date ran 1/30/2018 1:17:56Pb SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 1/30/2018 <br /> Record Selection Criteria: Facility ID FA0010425 <br /> Make changesicorrections 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 OW0008425 Case Number: H08067 w o er ID <br /> Owner Name 1.1X10., <br /> Owner DBA f- 'rf b.1n, <br /> Owner Address f.l7,l.{ . r-_ e,yunY1 st. <br /> 952,15 <br /> Cell +kime-Paene20Q,52 a_nana 5�n10— G-o I I 1 <br /> Work/Business Phone 269.52e-e444— r�q _..a Lk e— 1',14 <br /> Mailing Address _463G-E"LEG+(Rf)N-f�D t✓. <br /> 81 trY1 , cjt • C 5 Ll C) <br /> Care of <br /> FACILITY FILE INFORMATION Site Mitigation Facility <br /> Facility ID/CERS ID FA0010425 10183549 <br /> Facility Name <br /> Location 4343 E FREMONT ST <br /> STOCKTON, CA 95215 <br /> Phone _4511-1 -.I, N I <br /> Mailing Address . F 1- St. <br /> Care of ' 7111-In <br /> 111- e <br /> Location Code 99 - UNINCORPORATED A Alt Phone (p — Z <br /> BOS District 002 - MILLER, KATHERINE Fax �— <br /> APN 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 AR0017425 New Account ID: <br /> Mail Invoices to Account "�� Mail Invoices to: Owner / Facility / Account <br /> Account Name yet L1 �jC I?�, -TLL,& (Circle one) <br /> Account Balance as of 1/30/2018: $0.00 Y <br /> (Circle One) <br /> Transferto Activeractve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner.? Delete <br /> 1921 -HMBP-Regular-Primary Location PRO520340 EE0008709-JAMIE LIMA (_7 r *I) Inactive Y N I D <br /> 2220-SM HW GEN<5 TONS/YR PRO528554 EE0000031 -ELIANNA FLORIDO Inactive Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PRO612713 EE0000000-HAZ MAT SJC OES Inactive Y N ����(((( 1 D <br /> 2381 -UST FACILITY(BEFORE 1/84)-obsolete PR0232095 EE0000451 -STEVE SASSON Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE FE PRO51 D425 EE000o000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2831 -AST FAC >/=1,320-<10 K GAL CUMULATIVE PR0529235 EE0000031 -ELIANNA FLORIDO Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGE PRO533738 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andor protect speck,PHS'EHD hourly charges associated with this facility <br /> or idw,ty 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 andor Standards and State and'or <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 /> Payment Typ Check Number �1 Received by p <br /> EHD Staff: YY — Date_[L/�/ Account out: Date / / If a <br /> COMMENTS: ` I ',�,, ,rt ',,.,,r Invoice#: ��y'y <br />