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Date ren 2/14/2014 9:37:10AN SAN JOIN COUNTY ENVIRONMENTAL HEA i�DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 2/14/2014 <br /> Record Selection Criteria. Facility ID FA0021180 <br /> Make changes/corrections in RED ink. ( � <br /> INFORMATION CHANGE(dat <br /> NE (date) <br /> OWNER FILE INFORMATION N/Fed Tax ID <br /> Owner ID OW0017010 New Owner ID : <br /> Owner Name -BieseE_BlcEGt1R . Y-1 p3 N.1. cl$ F.r 1 i <br /> Owner DBA k C �,, .C'/J <br /> Owner Address •4g1Q I ARI LNI no 2 .Z ftil �� <br /> f r <br /> o�� r LA 5 41c 67- r <br /> Home Phone -Not Specified <br /> Work/BusinessPhone gg&gg6 g�� $0 23� - 5 Z .— <br /> Mailing Address-4-�MapIl _ 2 <br /> 04 o - r �y <br /> Care of �9PJ o 'K ,12_n et e <br /> Jr <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0021180 10,187,779 <br /> Facility Name KOMATSU FORKLIFT USA <br /> Location 3727 METRO DR STE F <br /> STOCKTON, CA 95215 <br /> Phone 209-467-7700 x0 <br /> Mailing Address 2792 MANDELA PARKWAY WAY <br /> OAKLAND, CA 95111 <br /> Care of <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOIS District 001 -VILLAPUDUA Fax <br /> APN 17925044 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 AR0038215 Account ID: <br /> Mail Invoices to Owner Mail Invoices to: ner / Facility / Account <br /> Account Name K O UA 0.fi_rLC Fo cVA- (Circle One) <br /> Account Balance as of 2/14/2014: $593.0 <br /> (Circle One) <br /> Transfer to Active/Inectve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner! Delete <br /> 1921 -HMBP-Regular-Primary Location PR0536898 EE0009817-ROBERT LOPEZ Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PRO638626 EE0001421 -STACY RIVERA Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andfor 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 anNor Standards and Slate ancVor <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 Receive <br /> REHS: Z Date 2 / 1 / ! Account out: Date <br /> COMMENTS: I <br />