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Date run 12124120144 11:37:421 SAN JC UIN COUNTY ENVIRONMENTAL /-IEA, l DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 12/24/2014 <br /> Record Selection Catena: Facility ID FA0015477 <br /> Make changestcorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID <br /> Owner ID OW0012430 New Owner ID <br /> Owner Name JACK NAGRA <br /> Owner DBA ALL GOOD PALLETS INC <br /> Owner Address 1055 DIAMOND ST <br /> STOCKTON, CA 95205 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-467-7000 <br /> Mailing Address PO BOX 937 <br /> RIPON, CA 95366 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID I CERS ID FA0015477 10184945 <br /> Facility Name ALL GOOD PALLETS INC <br /> Location 1055 DIAMOND ST <br /> STOCKTON, CA 95205 <br /> Phone 209-467-7000 x0 <br /> Mailing Address 1055 DIAMOND ST <br /> STOCKTON, CA 95205 <br /> Care of Jack Nagra <br /> Location Code 01 - STOCKTON Alt Phone <br /> BOS District 001 -VILLAPUDUA Fax <br /> Al 15514002 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 AR0026719 <br /> New Account ID. <br /> Mail Invoices to Owner Mall Invoices te: Owner / Facility / Account <br /> Account Name JACK NAGRA (Circle one) <br /> Account Balance as of 12/24/2014: $0.00 <br /> (Circle One) <br /> Transfer to Activellnacive <br /> ProgramlElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1920-HMBP-Common Materials PR0522706 EE0000006-HAZA SAEED Active Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PR0524504 EE0002622-BENJAMIN ESCOTTO Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0532006 Inactive Y N A I D <br /> BILLING and COMPLIANCI=ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site.andlor project specific,PHSIFHD hourly charges associated with INS 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 andfor Standards and Slate anClor <br /> Federal Laws. <br /> APPUCANT'S SIGNATURE: Date _f_/ <br /> Program Records to be TRANSFERED: `$25.00= Amount Paid Date 1 1 <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Check Number Received by <br /> REHS: Date 1 I Account out Date_J_/ <br /> COMMENTS. <br />