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i <br /> Date run 9/2/2011 1:46:01PM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 9/2/2011 <br /> Record Selection Criteria: Facility ID FA0018840 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> X Owner ID OW0001176 New Owner ID <br /> Owner Name CITY OF STOCKTON <br /> Owner DBA <br /> Owner Address 425 N EL DORADO ST <br /> STOCKTON,CA 95202 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-937-8377 <br /> Mailing Address 425 N.EL DORADO ST <br /> STOCKTON, CA 95202 <br /> Care of CITY OF STOCKTON <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0018840 <br /> Facility Name CITY OF STOCKTON <br /> Location 10200 LOWER SACRAMENTO RD <br /> STOCKTON, CA 95210 <br /> Phone <br /> Mailing Address 425 NORTH EL DORADO ST <br /> STOCKTON, CA 95202 <br /> Care of <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN NONE Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> I <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0033477 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name PRECISION SAMPLING (Circle One) j <br /> Account Balance as of 9/2/2011: $-500.00 <br /> ��J✓� (Circle One) <br /> ��r,°—'' Transfer to Active/inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner?, Delete <br /> I <br /> 2950-ENVIRON ASSESS PR0527792 EE0000684-MICHAEL INFURNA Ac e Y N A I D <br /> BILLING 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 this <br /> facility 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 Ordinace Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> �_ l <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 Received by <br /> REHS: Date / / Account out: l Date /,2—/ <br /> COMMENTS: <br /> 1 <br /> Alwle' tsC677-0 <br /> \\eh-env\envision\reports\5021.rpt <br />