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Date run 2/25/2015 10:44:54AI SAN JOi*w1UIN COUNTY ENVIRONMENTAL HEA;.o DEPARTMENT Report#5021 <br /> Run by <br /> Facility Information as of 2/25/2015 Pagel <br /> Record Selection Criteria Facility ID FA0009790 <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: 3 SSN/Fed Tax ID : <br /> Owner ID OW0007789 Case Number: H05424 New Owner ID <br /> Owner Name CITY OF STOCKTON FIRE DEPARTMENT <br /> Owner DBA <br /> Owner Address <br /> Home Phone Not Specified <br /> Work/Business Phone 209-397-8801 <br /> Mailing Address 425 N EL DORADO ST <br /> STOCKTON, CA 95202 <br /> Care of <br /> FACILITY FILE INFORMATION Site Mitigation Facility <br /> Facility ID/CERS ID FA0009790 10182909 <br /> Facility Name CITY OF STOCKTON FIRE STATION #7 <br /> Location 1767 W HAMMER LN <br /> STOCKTON, CA 95209 <br /> Phone 209-937-8801 x <br /> Mailing Address 1767 W HAMMER LN <br /> STOCKTON, CA 95209 <br /> Care of STOCKTON FIRE STATION#7 <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 003- BESTOLARIDES, STEVE Fax <br /> APN 07509036 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 AR0016790 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name CITY O O DEPARTMENT (Circle One) <br /> Account Balance as of 2/25/20 . $305.00 <br /> (Circle One) <br /> Active/InacNe <br /> PrograMElement and Description Record ID Employee ID and Name Status Ct _31 g* <br /> 1921 -HMBP-Reqular-Primary Location PR0539641 EE0000006-HAZA SAEED Active,l Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PR0512078 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2381 -UST FACILITY(BEFORE 1/84)-obsolete PR0232403 EE0000418-MICHAEL KITH Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PR0509790 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> 2840-AST EXEMPT FAC <1,320 GAL PR0528819 EE0000005-FATINAH ZAREEF Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,am Vor protect specific,PHS/EHD hourly charges associated with this facility <br /> or activity will be,billed to the Party idehbfreci as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes anNor Standards and State anclor <br /> Federal Laws <br /> APPLICANT'S 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 Receiv d y <br /> RENS: Dated/IS Account out: Date -2G/�/� <br /> COMMENTS: <br /> �Sl V.rL q f 4\ 5 <br />