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Date mn 7/3/2014 10:43:33AM SAN JC 'IN COUNTY ENVIRONMENTAL HEA DEPARTMENT Report#5021 <br /> Run by ,r <br /> Facility Information as of 7/3/201` Pagel <br /> Record Selection Criteria: Facility ID FA0022229 <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: 2 SSN/Fed Tax ID <br /> Owner ID OW0008055 Case Number: H06387 New Owner ID <br /> Owner Name CALIFORNIA DEPT FISH &WILDLIFE <br /> Owner DBA <br /> Owner Address 2109 ARCH AIRPORT RD 100 <br /> STOCKTON, CA 95206 <br /> Home Phone 209-234-3430 <br /> Work/Business Phone 209-640-4642 <br /> Mailing Address 2109 ARCH AIRPORT RD STE 100 <br /> STOCKTON, CA 95206 <br /> Care of HIEB, KATHY <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0022229 10444366 <br /> Facility Name CALIFORNIA DEPT OF FISH &WILDLIFE <br /> Location 2109 ARCH AIRPORT RD STE 100 <br /> STOCKTON, CA 95206 <br /> Phone 209-234-3430 <br /> Mailing Address 2109 ARCH AIRPORT RD STE 100 <br /> STOCKTON, CA 95206 <br /> Care of HIEB, KATHY <br /> Location Code 01 - STOCKTON Alt Phone <br /> BOS District 001 -VILLAPUDUA Fax <br /> APN 17731021 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name KATHY HIEB <br /> Title <br /> Day Phone 209-234-3484 <br /> Night Phone 209-640-4642 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0040560 NewAccount ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name CALIFORNIA DEPT OF FISH &WILDLIFE (Circle One) <br /> Account Balance as of 7/3/2014: $0.00 <br /> (Cine One) <br /> Transfer to Active/Inacive <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PRO538715 EE0009817-ROBERT LOPEZ Active Y N A I D <br /> 1962-CaIARP PROGRAM 2 FACILITY PR0538790 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> 1995-CalARP FAC STATE SURCHARGE FEE PRO538791 EEOo00000-HAZ MAT SJC DES Inactive Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PRO538714 EE0001421 -STACY RIVERA Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,anclor project specific,PHSIEHD hourly Merges 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 and'or Standards and State andfor <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 Received by <br /> REHS: Date_/ / Account out: Date <br /> COMMENTS: <br />