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Data run 10/15/2014 9:26:31A SAN JOAQUIN COUBLY- VVIRONMENTAL HEALTH DEPARTMENT Report 0I5021 <br /> Pagel <br /> Run by <br /> Facility Information as of 10/15/2014 <br /> Record Selection Criteria: Facility ID FA0020330 <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: 1 SSN/Fed Tax ID <br /> Owner ID OW0016691 New Owner ID <br /> Owner Name J & H MARINE <br /> Owner DBA <br /> Owner Address 2040 SAN ESTEBAN CIR <br /> ROSEVILLE, CA 95747 <br /> Home Phone 209-992-2958 <br /> Work/Business Phone 209-951-0283 <br /> Mailing Address 2040 SAN ESTEBAN CIR <br /> ROSEVILLE, CA 95747 <br /> Care of KOSTER, ERIC <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0020330 10187555 <br /> Facility Name J & H Marine <br /> Location 401 N SAN JOSE ST <br /> STOCKTON, CA 95203 <br /> Phone 209-951-0283 x <br /> Mailing Address 401 N SAN JOSE ST <br /> STOCKTON, CA 95203 <br /> Care of KOSTER, ERIC <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 001 -VILLAPUDUA Fax <br /> APN 13526016 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name ERIC KOSTER <br /> Title OWNER <br /> Day Phone 209-951-0283 <br /> Night Phone 209-992-2958 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0036311 New Account ID: <br /> Maillnvoicesto Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name J & H Marine (Circle One) <br /> Account Balance as of 10/15/2014: $155.00 Tff— 's C'l Cro <br /> �t.)[- 1 r ✓t a t ll �U (Circle One) <br /> Transfer to ActhasInsctve <br /> ProgramfElement and Description Record ID Employee IO and Name Status New Ovmer? Delete <br /> 1920-HMBP-Common Materials PR0539537 EE0000006-HAZA SAEED Active Y N A I D <br /> �ZU0-\M HW GEN<5 TONS/YR PR0535168 EE0009488-JEFFREY WONG Active Y N A D <br /> AST FAC >/=1,320-<10 K GAL CUMULATIVE PR0535169 EE0009488-JEFFREY WONG -_A llW ' , Y N A D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0535170 Inactivr Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT:. 1,the undersigned owner,operator or agent of same,acW wledge that all site,andior project specific,PHWEHD hourly charges associatedwith Nisfacility <br /> or activitywill be billed to the pant identified as the OWNER on this form. I also certify that all operations will be perrormed in accordance with all applicable Ordinance Codes andor Standards end State andor <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: Date I / <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 Re v y <br /> REHS: Vil, Date 16 /��/ Account out: Date l <br /> COMMENTS: <br /> A57 be-la, / 3za <br /> 222- �4 Lp <br />