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Date runes 4118!2013 8:16:01 AllR " Report#5021 <br /> SAN2U1QV COUNTY ENVIRONMENTAL HEI DEPARTMENT <br /> F:in:tjr` <br /> t <br /> Pagel <br /> Facility Information as of 4118/2013 <br /> Recordvia <br /> ction Crltertw Facility ID FA0020866 <br /> Make changes/corrections In RED Ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax.ID <br /> Owner ID OW0017157 New Owner ID <br /> Owner Name RICHARD DEBRUIN <br /> Owner DBA DEBRUIN CONSTRUCTION INC <br /> Owner Address 0 PO BOX 1355 <br /> FRENCH CAMP, CA_ 95231 " <br /> Home Phone Not Specified <br /> Work/Business Phone 209-462-5100 <br /> Mailing Address PO BOX 1355 <br /> FRENCH CAMP, CA 95;31 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID I CERS ID FA0020866 10,187,701 <br /> Facility Name DEBRUIN CONSTRUCTION INC <br /> "Location 1045 W CHARTER WAYJ° <br /> STOCKTON, CA 95206 ' <br /> Phone 209-462-5100 :X0 . <br /> I, Mailing Address PO BOX 1355 - <br /> FRENCH CAMP, CA 95231 w <br /> Care of _— <br /> .a,� . ... <br /> Location Code 01 STOCKTON <br /> Bas District 001 -VILLAPUDUA :` T <br /> APN16323039 <br /> .. <br /> x <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION. <br /> Contact Name 1 <br /> Title 2� <br /> Day Phone <br /> Night°Phone w 4 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> �.,�. <br /> Account ID AR0037485 f/-- - � <br /> Mail Invoices to Owner - `�N :count <br /> Account Name RI EBRUIN /I!" c . . <br /> Account Balance as of 4118120 3: $3,0.88.00 a '... <br /> i (Circle�� acts Aclivallnactve <br /> ProgramlElement and Description ecor ID Employee ID and Name " ^ - :. Delete <br /> X1921_-HMBP-Reg u lar-Primary Location_PR0536307_EE0009817-ROB ERT LOPEZ Inactive Y N A 1 D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHPRO536322 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> Ell Ll <br /> and COMPLIANCE ACKNOWLEDGEMENT, I,the undersigned owner,operator or agent of same,acknowledge that all site,andror project specific,PHS/EHD hourly charges 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 andlor Standards and State and'or <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: Date ! 1 <br /> Program Records to be TRANSFERED: " '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid, ate ! 1� <br /> Payment Type Check Number' Rece y <br /> REHS: Date 1 1 Account out: Date 1 ! <br /> COMMENTS: <br /> 1� <br /> AjV - • <br />