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Dates 711/2015 8:37:23AM SAN JOAQUIN COUNTY ENVIRnNMENTAL HEALTH DEPARTMENT Report #5021 <br />Run by Pagel <br />Facility Information as of 7/1/2015 <br />Record Selection Criteria: Facility ID FA0019717 <br />OWNER FILE INFORMATION Number of facilities for this owner <br />Owner ID <br />OW0016174 <br />Owner Name <br />NATURE -KIST - <br />Owner DBA <br />f h f4JftE-1ff5i <br />Owner Address <br />1820 INDUSTRIAL DR <br />STOCKTON, CA 95206 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />289-944-7-= <br />Mailing Address <br />RQ BQ,X 7027 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility lD/CERS ID FA0019717 10187355 <br />Facility Name <br />Location 1820 INDUSTRIAL DR <br />STOCKTON, CA 95206 <br />Phone •r <br />n09 nee 720n !onte „--- <br />Mailing Address P6-SCOC' r—' <br />Foonnnni-r CA 94537 7n97- <br />Care of <br />Location Code 01 -STOCKTON <br />Bos District 001 - VILLAPUDUA, CARLOS <br />APN 17732012 M <br />EMERGENCY NOTIFICATION CONTACT INFORMATION ` <br />Contact Name �+( <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0035079 <br />Mail Invoices to Owner <br />Account Name NAIU <br />Account Balance as of 7/1/2015: 0 <br />0 <br />;��O <br />.3-70 - <br />Make changesicorrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />SSN / Fed Tax ID <br />New Owner ID <br />�O✓L�,��� •�Sa.<,vCR� a-C-.dJ 2✓`P <br />�noftAn _4ty ✓L�, �� <br />2 O � NCIH Kir V <br />G <br />Alt Phone ? Q et Z-7 -2- f <br />Fax <br />EMail : <br />Tincd C) L_�' <br />rvlaK w 1/ <br />o -> - S <br />zoi- zq2 5-L Site <br />Mail Invoices to: <br />_2..ai LF <br />New Account to: : <br />Owner / Facility / Account <br />(Circle One) <br />(Circle One) <br />Transfer to Active/Ineche, <br />02�0- <br />lament and Description Record ID Employee 10 and Name Status New Owner? Delete <br />MBP -Common Materials PR0529880 EE0009817 - ROBERT LOPEZ Inactive Y N D <br />ERSC- ELECTRONIC REPORTING STATE SURCHARG PR0533012 Inactive Y N 1 D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, ander project specific, PHS'EHO hourly charges associa ed with this facility or; <br />be billed to the party identified as the OWNER on this form l also certify that all operations vlil) be performed in accordance with all applicable Ordinance Codes andor Standards and Stale ander Federal Lati <br />'w � s K . <br />APPLICANT'S SIGNATURE: Date <br />Program Records to be TRANSFERED: " $25.00 = Amount Paid Date /I <br />Water System to be TRANSFERED: Amount Paid Date /I <br />Payment Typ Check Number Receive b <br />EHD Staff: �--Z— Date �l� f l� Account out: Date <br />COMMENTS: <br />I (� Invoice#: 0V��-7� <br />