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1/9/2015 8:33:47AM <br /> Run by SAN JOA <br /> QUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Record Selection Criteria: Facility it) <br /> FA0009942 Facility Information as of 1/9/2015 <br /> Pagel <br /> Make changea/Oorrections in RED ink. <br /> OWNER FILE INFORMATION Number of facilities for this ow INFORMATION <br /> C <br /> Owner lD pW0001008 ner: 1p OWNERSHIPCHgNGE(date) <br /> SSN = <br /> Owner Name CALTRANS/DISTRICT 10 New Fetl Tax ID <br /> Owner DBA New Owner ID <br /> Owner Address PO BOX 2048 <br /> STOCKTON, CA 95201 <br /> Home Phone 209-483-3088 <br /> WOrk/Business Phone 209-948-3723 <br /> Mailing Address PO BOX 2048 <br /> Care of STOCKTON, CA 95201 <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0009942 <br /> Facility Name CAL TRANS (LINCOLN ST) 49 <br /> Location 312 S LINCOLN ST <br /> STOCKTON, CA 95206 <br /> Phone 209-948-7109 x <br /> Mailing Address 312 S Lincoln ST <br /> STOCKTON, CA 9520.6 c� t•s- <br /> Care of Caltrans/ Landscape <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 001 -VILLAPUDUA Fax <br /> APN 13734020 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone / _17)1') /..f1— <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0016942 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name Scott Waller (Circle one) <br /> Account Balance as of 1/9/2015: $0.00 <br /> (Circle One) <br /> Transfer to AcliveAnachre <br /> ProgramrElemeat and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Reqular-Primary Location PRO520348 EE0009817-ROBERT LOPEZ Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PR0517886 EE0001421-STACY RIVERA Inactive Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PR0512230 EE0000000-HAZ MAT SJC OES Inactive Y N A 1 D <br /> 2381 -UST FACILITY(BEFORE 1/84)-obsolete PRO231157 EE0000418-MICHAEL KITH Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PR0509942 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PRO523809 EES555555-Garrett Alias-Backus Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0533049 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT I,the undersigned owner,operator or agent ofsame,acknowledge that all site,andor project speafic,PHSIEHD hourly charges associated with Mis f.lAy <br /> or activity w it be billed to the party identified as Ne OWNER on this form I alsa certify that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and State ander <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 b <br /> REHS: \�'�AU�• Date Z( lel ZvK Account out: _ Date <br /> COMMENTS r �G pti.. 11\ I�{ <br /> V ,� <br /> �wt,y a ZiV l� sCH im' <br />