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Date run 911112014 4:02:40Ph SAN JI 2UIN COUNTY ENVIRONMENTAL HEi H DEPARTMENT Repott850kl <br /> Pagel <br /> Run by �+.. Facility Information as of 9/11/2014 <br /> Record Selection Criteria: Facility 11) FA0002168 <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 OW0001686 New Owner ID <br /> Owner Name ST MARYS HIGH SCHOOL <br /> Owner DBA ST MARYS HIGH SCHOOL <br /> Owner Address 5648 N EL DORADO ST <br /> STOCKTON, CA 95207 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-957-3340 <br /> Mailing Address 5648 N EL DORADO ST <br /> STOCKTON, CA 95207 <br /> Care of ST MARYS HIGH SCHOOL <br /> FACILITY FILE INFORMATION Site Mitigation Facility <br /> Facility ID f CERS ID FA0002168 10180883 <br /> Facility Name ST MARYS HIGH SCHOOL <br /> Location 0648 N EL DORADO ST <br /> STOCKTON, CA 95207 <br /> Phone 209-957-3340 <br /> Mailing Address PO BOX 7247 <br /> STOCKTON, CA 952670247 <br /> Care of ST MARYS HIGH SCHOOL <br /> Location Code 01 - STOCKTON Alt Phone <br /> BOS District 002 - RUHSTALLER, LARRY Fax <br /> APN 10209001 EMaii: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION' <br /> Account ID AR0002179 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner I Facility / Account <br /> Account Name ST MARYS HIGH SCHOOL (Circle One) <br /> Account Balance as of 9/1112014: $0.00 <br /> (Circle One) <br /> Transfer to Activellnactve <br /> Program/Element and Description Record 10 Employee ID and Name Status New Owner? Delete <br /> 1626-RESTAURANT/BAR 101 +SEATS PRO160855 EE0001084-STEPHANIE RAMIREZ Active Y N A I D <br /> 1921 -HMBP-Reqular-Primary Location PRO530852 EE0000006-HAZA SAEED Active Y N A I D <br /> 2381 -UST FACILITY(BEFORE 1/84)-obsolete PR0231089 EE0000418-MICHAEL KITH Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PRO507296 EE0000418-MICHAEL KITH Inactive Y N A I D <br /> 3611 -PUBLIC POOLISPA-PRIMARY PR0527393 EE0001084-STEPHANIE RAMIREZ Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO532561 Inactive Y N A I D <br /> 4630-NTNC WATER SYSTEM WAD461209 EE0005838-ADRIENNE ELLSAESSER Active 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,PHSrEHD 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 andfor Standards and State and'or <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date 1 I <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date 1 I <br /> Water System to be TRANSFERED: Amount Paid Date 1 I <br /> Payment Type Check Number Received by <br /> REHS: Date 1 I Account out: Date ! I <br /> COMMENTS: <br />