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Date run 6/5/2017 5:01:46PM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 6/5/2017 <br />Record Selection Criteria: Facility ID FA0023772 <br />Make changes/comections in RED ink. / <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />OWNER FILE INFORMATION Number of facilities for this owner <br />Owner ID <br />OW0022108 <br />Owner Name <br />Golden State Bridge Inc. <br />Owner DBA <br />OwnerAddress <br />3701 MALLARD DR <br />BENICIA, CA 94510 <br />Home Phone <br />925-372-8000 <br />Work/Business Phone <br />925-372-8000 <br />Mailing Address <br />3701 Mallard Drive <br />Benicia, CA 94510 <br />Care of <br />LANZA, MARIA <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID <br />FA0023772 10718107 <br />Facility Name <br />Golden State Bridge Stockton Yard <br />Location <br />321 Lipes Dr <br />Stockton, CA 95205 <br />Phone <br />925-372-8000 x <br />Mailing Address <br />3701 Mallard Drive <br />Benicia, CA 94510 <br />Care of <br />Golden State Bridge Inc. Stockton Yard <br />Location Code <br />BOIS District <br />APN <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name LANZA, MARIA <br />Title <br />Day Phone 925-372-8000 <br />Night Phone XThomas <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />SSN / Fed Tax ID <br />New Owner ID : <br />Alt Phone <br />Fax <br />El <br />Account ID AR0044002 <br />Mail Invoices to Account Mail Invoices to: <br />Account Name Stefany Russell <br />Account Balance as of 6/5/2017: $0.00 <br />New Account ID: : <br />Owner / Facility / Account <br />(Circle One) <br />(Gird. One) <br />Transfer to Active#nacNe <br />ProgramlElement and Description Recom ID Employee ID and Name S New Owner' Delete <br />1921 - HMBP-Reqular-Primary Location PRO541466 EE0009817 - ROBERT LOPEZ Inactive Y N A D <br />2239- REMOTE WASTE CONSOLIDATION SITE PR0541484/ EE9999996 - THREE VACANT3 Inactive Y N A D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1, the undersign! owner, operator or agent of same, acknowledge that all site, and/or pmlect or. PHSEHD hood a,gas a..0_.ed with ass facility <br />or advity will be billed W Ne party identified as the OWNER on #,is fano. I also certify Mat all operators will be perfanoed in accomanoe with all appl N. ptlinence s anwor BIndaNs and State andbr <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 Type Check Number Received <br />EHD Staff: Date./_�/ Account out: Date / 7 <br />COMMENTS: <br />Invoice #: <br />