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Date run 10/13/2017 9:04:50A SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by DONNA Pagel <br /> Facility Information as of 10/13/2017 <br /> Record Selectloh Cntena: Facility ID FA0010370 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) 7 <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 2 SSN/Fed Tax ID <br /> Owner ID OW0009604 New Owner ID <br /> Owner Name <br /> Owner DBA i / L _ <br /> OwnerAddress .p8-8'0X-31-S4§_ 236 AI, <br /> Oc `z-c, <br /> Home Phone Not Specified <br /> Work/BusinessPhone 2D9 4- — Xq 2Y-7 <br /> Mailing Address gqg, a ,•✓ ,� <br /> C A 51-2-O <br /> Care of MGbEH kN KE Y- i <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0010370 10592446 <br /> Facility Name �. f , .It ,i YX <br /> Location 1200 N GOLDEN GATE AVE <br /> of A 95205 <br /> Phone-2� fi l ? - Z y79 <br /> Mailing A <br /> Care of S, IS C <it—LO S` <br /> Location Code 99- UNINCORPORATED A Alt Phone <br /> BOS District 002 NP max <br /> APN Lr✓rt -� ,"' 4tf EMCII: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0017370 New Account ID: <br /> Mail Invoices to Account ( Mail Invoices to: Owner / Facility / Account <br /> Account Name Kelvin—^^I ^arra-ro�^rte 1 (Circle One) <br /> Account Balance as of 10/13/2017: $298.00 C,IVt <br /> lei 2© (ctwer One) <br /> Transfer to Active/InaMve <br /> Program/Element an Oe cnplion Record ID Employee ID and Name Status New Owner? Delete <br /> 1a HMBP-Reqular-Primary Location PRO521228 EE0009817-ROBERT LOPEZ Inactive Y N ® I D <br /> 2220-SM HW GEN<5 TONS/YR PRO514299 EE9999996-THREE VACANT3 Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PRO612658 EE9999996-THREE VACANT3 Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE FI PRO510370 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1,the undersigned owner,operator or agent of same,acknowledge that all site,and'or project specific,PI-SEHO hourly charges associated with this facility <br /> or activity 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 andror Standards and State andror <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: $25.00= Amount Paid Date / / <br /> Water System to be T NSFERED: Amount Paid Date <br /> Payment Typ r Cck Number Received y / <br /> EHD Staff: ��L Date��/ / Account out: DateIrv/ t� I��/7 <br /> COMMENTS: nvoice#: 3015 (2i <br /> I <br /> Tinotne- dLs cohnec�ecl ��eaSe Gdvtse . <br />