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pale re 3/25/2014 2:58:5OPh SAN X(. IN COUNTYz'3NVIRONMENTAL HEA,,i DEPARTMENT Report#5021 <br /> Run by f Pagel <br /> Facility Information as of 3/25/2014 <br /> Record Selection Criteria: Facility ID FA0021146 <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: 1 SSN/Fed Tax ID <br /> Owner ID OW0017421 New Owner ID <br /> Owner Name KINGSDOWN INC <br /> Owner DBA KINGSDOWN INC <br /> Owner Address 1631 INDUSTRIAL DR <br /> STOCKTON, CA 95206-4983 <br /> Home Phone Not Specified <br /> Work/Business Phone 800-800-1353 <br /> Mailing Address 1631 INDUSTRIAL <br /> Me6aw\e NG a 13b1 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0021146 10,187,773 <br /> Facility Name KINGSDOWN INC <br /> Location 1631 INDUSTRIAL DR <br /> STOCKTON, CA 95206 <br /> Phone 209-234-1436 <br /> Mailing Address 1631 ,`,Q '„STRIA! DF <br /> v � 3 Ftp e/ t lC 31�� <br /> Care of <br /> Location Code 01 - STOCKTON Alt Phone <br /> BOIS District 001 -VILLAPUDUA Fax <br /> APN 17732007 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 AR0038131 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name KINGSDOWN INC (Circle One) <br /> Account Balance as of 3/25/2014: $290.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee IO and Name Status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PRO536814 EE0009817-ROBERT LOPEZ Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO536826 Inactivt Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andor Project specific,PHSIEHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this form. I also candy that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and State andor <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 Received by <br /> REHS: Date / / Account out: Date 6 <br /> COMMENTS: <br />