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Date run 11/6/2018 3:17:38PN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 11/6/2018 <br /> Record Selection Criteria: Facility ID FA0021370 <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 : 20 SSN/Fed Tax ID <br /> Owner ID OW0008853 Case Number: H08879 New Owner ID <br /> Owner Name San Joaquin County <br /> Owner DBA PUBLIC WORKS <br /> Owner Address 1810 E HAZELTON AVE <br /> STOCKTON, CA 95205 <br /> Home Phone 209-468-3057 <br /> Work/Business Phone 209-468-3090 <br /> Mailing Address 1702 E. Scotts <br /> Stockton, CA 95205 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0021370 10187823 <br /> Facility Name SJC PUBLIC WORKS/UTILITY WILKINSON <br /> Location WILKINSON <br /> STOCKTON, CA 95212 <br /> Phone 209-468-3091 <br /> Mailing Address 1702 E SCOTTS AVE <br /> STOCKTON, CA 95205 <br /> Care of <br /> Location Code 99- UNINCORPORATED A Alt Phone <br /> BOS District 004 -WINN, CHARLES Fax <br /> APN 08668060 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 AR0038735 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name SJC PUBLIC /U ILITY WILKINSON (Circle One) <br /> Account Balance as of 11/6/2018: $ .00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Odfiety 1921 -HMBP-Reqular-Primary Location PR0537242 EE0008709-JAMIE LIMA Active Y N ABILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific,PHS/EHD hourly charges associated with <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 and/or Standards and State and/or <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <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 Receiveby <br /> EHD Staff: Date / / Account out: Date <br /> COMMENTS: <br /> Invoice#: <br />