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Date run 4/27/2017 2:16:37Pk SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report 95021 <br /> Run by Pagel <br /> Facility Information as of 4/27/2017 <br /> Record Seledion Criteria: Facility ID FA0023984 <br /> Make changesicorrections 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 OW0022444 New Owner ID <br /> Owner Name Tiger-SUI <br /> Owner DBA <br /> Owner Address <br /> Home Phone Not Specified <br /> Work/Business Phone 209451-2725 <br /> Mailing Address PO BOX 2089 <br /> Stockton, CA 95201 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0023984 10721335 <br /> Facility Name Tiger-SUI <br /> Location 65 Stork Rd <br /> Stockton, CA 95203 <br /> Phone 209-451-2725 x <br /> Mailing Address PO BOX 2089 <br /> Stockton, CA 95201 <br /> Care of Ozzie Gomez <br /> Location Code Alt Phone <br /> BOIS District Fax <br /> APN 14502004 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0044525 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name Ozzie Gomez (Circle One) <br /> Account Balance as of 4/27/2017: $0.00 <br /> (Circle One) <br /> Transfer to Activerrac rte <br /> ProgrannElemenl and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PRO541826 EE0009817-ROBERT LOPEZ Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PRO541825 EE0001421 -STACY RIVERA Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersignecl owner,operator or agent of same,acknowledge that all site,andor Project specific,PHS/EHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER an this form I also certify that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and State ardor <br /> Federal Lewis <br /> APPLICANTS SIGNATURE: Date ! / <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date / / <br /> Water System to be TRANSFERED: Amount Paid Date I / <br /> Payment Type _ Check Number Received by <br /> � <br /> EHD Staff: ✓�o,^ Date / 7 /j_ Account out: jj�' Date / Zp /j_ <br /> COMMENTS: Involce#: <br /> NeIP PR5 G/u.-1'e& Lrrv. CIRRS yubb-144,t w, 40/17t SwMc. '" FA . %111 •,v 17 c. aji <br /> Saw. &_ <br />