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Date run 1/9/2013 4:48:58PM SAN JCA,,.UIN COUNTY ENVIRONMENTAL HEA I DEPARTMENT Report#5021 <br /> Run by -.01 Pagel <br /> Facility Information as of 1/9/2013 <br /> Record Selection Criteria: Facility ID FA0016414 <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 OW0013287 New Owner ID <br /> Owner Name OLDCASTLE APG <br /> Owner DBA OLDCASTLE-APG <br /> Owner Address 4202 GIBRALTAR CT <br /> STOCKTON, CA 95206 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-983-1609 <br /> Mailing Address 10714 POPLAR AVE <br /> FONTANA, CA 92337 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0016414 <br /> Facility Name OLDCASTLE APG <br /> Location 4202 GIBRALTAR CT <br /> STOCKTON, CA 95206 <br /> Phone 209-983-1609 x0 <br /> Mailing Address 10714 POPLAR AVE <br /> FONTANA, CA 92337 <br /> Care of <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 17728043 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0028875 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to Owner / Facility / Account <br /> Account Name OLDCASTLE APG (circle One) <br /> Account Balance as of 1/9/2013: $0.00 <br /> (Circle One) <br /> Transfer to Activennadve <br /> Program/Element and Description Record ID Employee ID and Name Status Nev,Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PRO524471 EE0009817-ROBERT LOPEZ Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCFLPR0531513 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned ow,»r,operator or agent of same,actmowledge that all site,ardor protect specific.PHS/EMD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on Nis form I also certify that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and State ander <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 /> RENS: Date_/ /_ Account out: Date_/_/ <br /> COMMENTS: <br />