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Date run 6/16/1014 12:25:45PI SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report AS021 <br /> Run by Paget <br /> Facility Information as of 6/16/2014 <br /> Record Selection Criteda: Facility ID FA0020330 ,y <br /> `D' \I Make changestcorrections in RED Ink. <br /> INFORMATION CHANGE(date) �� �' Z� <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE IN ORMATION Number of facilities for thisow r: 1 SSN/Fed Tax ID <br /> Ownerlo OW0016691 New Owner ID <br /> Ow at Name <br /> O erDBA aQ GA-A) STFAA1Q L11?- <br /> Owner ddress �ncE.yrt-L�,rA C1 m�/7 <br /> Home hone 209.4$4-141-1.— Lj CCI <br /> Work/Business one Not Specified r3 <br /> Mailing A ass- O( Sc y J o f <br /> S' DC(C 17IL1 <br /> Car of Yt G LGoS'4-2-l" <br /> FACILITY FILE INFORMA ION <br /> Facility ID/CERS I FA0020330 10187555 M C"N//LQ <br /> Facility Name <br /> Location 01 NS JOSE ST <br /> S OCK N, CA 95203 <br /> Phone _ p� 7 g 3 <br /> Mailing Address 401 AN JOSE ST !! <br /> STO KTON, CA 95203 <br /> Care of FA JOSEPH <br /> Location Code 0 -S OCKTON Alt Phone <br /> BCS District 1 -V IAPUDUA Fax <br /> APN 35260 6 EMail: _� y , L yjgg iW "-p)yt <br /> EMERGENCY NOTIFICAT ON CONTA T INFORMATION I/ <br /> Contact N e y t G k 8 ,S-kp-f <br /> itle <br /> Day hone <br /> Nig Phone <br /> ACCOUNTS REC VABLE FILE INFORM TION <br /> Account ID AR0036311 NewAocount ID: <br /> it Invoices to Facility y' (�µA.J� Mail Invoices to: Owner / Facility / Account <br /> Account Name DELTA MARINES RVICES INC ZO �mo>w (Circle One) <br /> Account B ance as of 6/16/2014: $0.00 <br /> p/�� �� ,` , 9 �M k� <br /> PrograrNE mount and Description Record ID Employee ID and NameStatus Transfer to Activellnsctve <br /> New Owner? Delete <br /> 222 -SMHWGEN<5TONS/YR PR0535168 EE0009488-JEFFREY WONG Active Y N A I D <br /> 2831 -AST FAC >/=1,320-<10 K GAL CUMULATIVE PR0535169 EE0009488-JEFFREY WONG Active,? Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO535170 Inactivf Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of soma,acknowledge that all site,andor protect spec.PHSIEHD hourly charges associatetl with this facility <br /> or activitywill ots billed to <br /> PeM1y identified�astl,e OWNER <br /> 3`75 form also certify that�a�pere ���� in dance tw applicable i�notl�endor Slentl ra ds enasset D <br /> Federal Laws. /JJ``JJ 37 (C`�7J 111 ,,71r "-'/f/`Dy(S(/F/��-J <br /> APPLICANTS SIGNATURE: Date / I <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRAN FERED: Amount Paid Date <br /> Payment Type Pheck Number Receiv d y <br /> RENS: Date I / Account out: <br /> COMMENTS: � v '�^[1r / �BC/l ✓�V <br />