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Date run 2/19/2013 9:49:05AK SAN JO! IIN COUNTY ENVIRONMENTAL HEAI ' DEPARTMENT Report#5021 <br /> Run by ate/ Pagel <br /> Facility Information as of 2/19/2013 <br /> Record Selection Criteria: Facility ID FA0020359 <br /> Make changesicorrections in RED Ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0015115 New Owner ID <br /> Owner Name WEYERHAEUSER <br /> Owner DBA WEYERHAEUSER <br /> Owner Address 1111 HUMPHREYSAVE <br /> STOCKTON, CA 95203 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-942-1825 <br /> Mailing Address 1111 HUMPHREYSAVE <br /> STOCKTON, CA 95203 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0020359 <br /> Facility Name WEYERHAEUSER <br /> Location 1004 HUMPHREYS AVE <br /> STOCKTON, CA 95203 <br /> Phone 209-942-1825 x0 <br /> Mailing Address 1111 HUMPHREYSAVE <br /> STOCKTON, CA 95203 <br /> Care of <br /> Location Code Alt Phone <br /> BOS District 003 - BESTOLARIDES Fax <br /> APN 16203007 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 AR0036346 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name WEYERHAEUSER (Cil One) <br /> Account Balance as of 2/19/2013: $135.00 <br /> (Circle One) <br /> Transferto Achweilnictve <br /> Progre"Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1920-HMBP-Common Materials PR0535244 EE0009817-ROBERT LOPEZ Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCH PRO535273 Inactive Y N A 1 D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andor project specific,PHS/EHD 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 ander Standards and State anchor <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 I / <br /> COMMENTS: <br />