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Data nun 8/18/2014 11:13:44AI SAN JC UIN COUNTY ENVIRONMENTAL HEA i DEPARTMENT Report#5021 <br /> Run by <br /> Facility Information as of 8/18/2014 Pagel <br /> Record Selection Criteria: Faulty ID FAD009376 <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: 10 SSN/Fed Tax ID <br /> Owner ID OW0001008 New Owner ID <br /> Owner Name Caltrans <br /> Owner DBA <br /> Owner Address PO BOX 2048 <br /> STOCKTON, CA 95201 <br /> Home Phone 209-483-3088 <br /> Work/Business Phone 209-948-3723 <br /> Mailing Address P.O. BOX 2048 <br /> Stockton, CA 95201 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0009376 10001884 <br /> Facility Name Caltrans-District 10 Office <br /> Location 1976 E Charter Way <br /> Stockton, CA 95205 <br /> Phone 209-948-7543 x <br /> Mailing Address P O Box 2048 <br /> Stockton, CA 95201 <br /> Care of Cal Trans <br /> Location Code 01 - STOCKTON Alt Phone <br /> BOS District 001 -VILLAPUDUA Fax <br /> APN 16918002 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0016376 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name Caltrans (Circle One) <br /> Account Balance as of 8/18/2014: $0.00 <br /> (Circle One) <br /> Transfer to Acivel.Me <br /> ProganvElement and Description Rewrd ID Employee ID and Name Status New Owner? Delete <br /> 1920-HMBP-Common Materials PRO519589 EE0000006-HAZA SAEED Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PR0513800 EE0001421 -STACY RIVERA Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PRO511664 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> 2226-CalARP PROGRAM PRO514573 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2381 -UST FACILITY(BEFORE 1/84)-obsolete PR0500379 EE0000008-LETITIA BRIGGS Inactive Y N A I D <br /> 2381 -UST FACILITY(BEFORE 1/84)-obsolete PR0500385 EE0000008-LETITIA BRIGGS Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PR0509376 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PRO523689 EE0003611 -FRANK GIRARDI Active Y N A 1 D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO531897 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andor project specific,PHSIEHD hourly charges associated with this facility <br /> or activity will be billetl to the party identified as the OWNER on this form. I also wrtify that all operations will be Performed in accordance with all applicable Ordinance Codes andor Standards end State andfor <br /> Federal Laws. <br /> APPLICANTS 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 />